



•i ;■ . L I j^*» •¥■.! ■lilt' ; il '.,'., 1. ',■ r , 








Class. 
Book 



COPYRIGHT DEPOSIT 



A SYSTEM OF 



OBSTETRICS 



WITH FIVE HUNDRED AND THIRTT-SEVEN ILLUSTRATIONS; 
BASED UPON A TRANSLATION FROM THE FRENCH 

OF/AUVARD 



REVISED BY 



CURTIS M. BEEBE, M. D. 



CHICAGO, ILL. 



Jan bi 1893 



fi'^66X' 



1892 
J. B. FLINT ^ COMPAlSry 

NEW YORK 



'J 



Copyright, 

1892, 

J. BENTON FLINT. 



THE MERSHON COMPANY PRESS, 
RAHWAY, N. J. 



CONTENTS. 



I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 
XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 
XIX. 

XX. 

XXI. 

XXII. 

XXIII. 

XXIV. 

XXV. 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 

XXX. 

XXXI. 

XXXII. 

XXXIII. 

XXXIV. 



"^ PAGE. 

Menstruation and Fecundation, . . . . . 17 
Development and Description of the Human Ovum, , 27 
Modification of the Maternal Organism, . . 64 

The Parturient Canal, 84 

Presentations and Positions, ..... 97 

Symptomatology of Pregnancy, 127 

The Diagnosis of Pregnancy, . . . . . 158 
Progress and Duration of Pregnancy. — Prognosis. — 

Hygiene, 164 

Accouchement. — Maternal Phenomena, . . . 170 

Phenomena of the Appendages 188 

Mechanism of Accouchement. — Fetal Phenomena, . 194 
Influence of Accouchement on the Mother and on 

the Child, 214 

Management of the Accouchement 224 

Accouchement.— Delivery of the Appendages, . 234 

Post-Partum, 240 

Puerperal Pathology.— General Disease.— Eclampsia. 250 

Puerperal Septicemia, 257 

Puerperal Pathology. — Extra Genital Localized 

Diseases, 269 

Diseases of the Bony Pelvis, 277 

Diseases of the Genital System and its Dependen- 
cies.— Genital Dystocia, . . . . . .307 

Diseases and Anomalies of the Placenta, . . 324 
Diseases of the Ovuline Envelopes, . . . .335 



Diseases and Death of the Fetus. — Fetal Dystocia, 338 



Multiple Pregnancy, 

Premature Expulsion, .... 
Accidents of Accouchement, 
Accidents of the Delivery of Appendages, 
Accidents of Post-Partum, .... 
The Vectis or the Lever, 

Versions, 

Forceps, 

Manual Extraction, 

Induced Expulsion, 

e3ibry0t0my, 

Hysterotomy. — Cesarian Section, . 



348 
359 
368 
376 
389 
391 
392 
402 
416 
420 
423 
432 



TREATISE ON OBSTETRICS. 



CHAPTER I. 



MENSTRUATION AND FECUNDATION. 

Woman's life is divided into three great periods : one, prsegenital ; 
another, genital; the third, post-genital. The first extends from 
birth to the first menstruation; the second, from puberty to the 
menopause, and the last, from the menopause to the close of life. 

Only the genital period interests the obstetrician, for it is that 
portion of woman's hfe that is consecrated to procreation. In im- 
posing this role upon woman, nature has established in her a pre- 
ponderance of the genital system, an idea that Michelet has so well 
expressed in the words, "Woman is a matrix supplied with organs." 

This genital system, which dominates the feminine organism, 
imposes three different states, that successively divide the genital 
period. For a time there is repose, calm, an intermittent and a 
regular truce accorded to the economy. Then there is the prepa- 
ration for fecundation, the period of emission of the ovule, the 
menstrual state. Sometimes, finally, after the meeting and the 
union of the two elements, male and female, a being developes in 
the interior of the uterus, and causes in the ge stating woman a 
series of changes necessary to ensure tliis new life ; this epoch is 
designated as the puerperal state. Thus, a state of repose, a men- 
strual state and a puerperal state occur during the genital life of 
woman. It is the puerperal state that especially interests the 
obstetrician. Obstetrics is the study of the puerperal state, pro- 
vided this term is used to designate the period which extends from 
impregnation to the end of lactation, or to the end of the third 
month after delivery when the mother does not nurse her child. 

Before entering upon the study of pregnancy it will be necessary 
to consider briefly menstruation and fecundation, which are its pre- 
liminaries to pregnancy. The term menstruation is apphed to the 
flow of blood, which occurs periodically from the female genital 
organs. Menstruation comprises two essential phenomena, ovu- 
lation and a sanguineous flow. Each demands a special study. 

Ovulation is the liberation by the ovary of a cell, having an 
important future and to which has been given the name o^aile. 



18 



Menstruation and Fecundation. 



A word on the ovary and its contents. The ovary, situated in 
the posterior wing of the broad Hgament, is a small gland resembling 
an almond in form. It measures four centimetres in length, two in 
height and one centimetre and a half in its antero-posterior thick- 
ness; its weight is eight grammes. Its two surfaces and its 
superior border being free it floats in the peritonaeal cavity. Its 
inferior border is attached by a ligament to the uterus and to the 
pavilion of the tube by one of its fimbricie. I shall return to the 
anatomical relations of the ovary in connection with the subject of 
fecundation. 




Fig. I. — Section of a fragment of the cvary. 6' 6", ovarian stroma: ^, epithelium; 
I I, Graafian follicles highly developed; 2 2, non-developed follicles; 3, very small 
follicles; O, ovule in the Graafian follicle; vv, bloodvessels; 9, cells of the granular 
membrane. 

On section, the structure of the ovary is found of a reddish color, 
rose colored in some parts, a deeper red in others. This is the 
bulbus portion, a mixture of non-striated mucular fibres, con- 
nective tissue fibres, arteries, veins, lymphatics and some nerve 
filaments. This bulbus portion forms almost the whole of the 
ovary. It is covered by a thin envelope, which scarcely measures 
a millimetre in thickness. 

The peripheral portion, called the fibrous tunic by the older 
writers, is distinguished from the subjacent portion by its pale 
color, its apparent homogeneousness and by its firmness. This 
envelope is the fundamental portion of the ovary. It is formed by 
the accumulation of ovisacs, also called ovarian vesicles or Graafian 
follicles. It is in the interior of these vesicles that the ovule is found. 

Contrary to Avhat is observed in all the other glands of the organ- 
ism, the ovary has its cavity at the surface and it is there that the 
phenomenon of ovulation takes place. To comprehend the phe- 
nomenon a complete description of the ovisac and its contents is 



Menstruation and Fecundation. 



19 



indispensable. The follicle contains an accumulation of other cells, 
among them one of particular character, the ovule. The ovule is 
the female primordial element, just as the spermatozoid is the pri- 
mordial element of the male. The ovule is constituted by the 
germinative spot, the germinative vesicle, the vitellus and vitelline 
membrane. The ovule is contained in the interior of the ovarian 
vesicle surrounded by cells, the whole being enveloped in a common 
membrane. Altogether these structures form the ovisac. In its 
conformation the ovule does not differ from ordinary cells. Each 
ovisac contains an ovule, and each ovary contains, as M. Sappey 
has demonstrated, approximately 300,000 ovisac, or 600,000 to each 
woman. 




Fig. 2. — Schematic representation of the Graafian follicle or ovisac 
and of its contents, the ovule. 

Let us follow an ovisac in its menstrual evolution. In its interior 
the cells assume proliferation and at one point a cavity is formed, 
that fills with liquid, perhaps the result of the cellular activity. 
The vesicle enlarges markedly under the influence of the cell pro- 
liferation and of the accumulation of liquid. It takes on a size 
that becomes visible to the naked eye at the surface of the ovary. 



20 



Menstruation and Fecundation, 



This swelling continues and the vesicle, instead of remaining 
spherical, takes an ovular form, with the small extremity corre- 
sponding to the free surface of the ovary. At the moment when 
the distention becomes too great, rupture occurs at the most pro- 
jecting point. This rupture, prepared for by the modifications in 
the ovisac, is provoked by the congestion of the bulbus portion of 
the ovary. This congestion occurs under the influence of menstru- 
ation or any genital excitation, such as that produced by coitus. 




Fig. 3. — Ovisac preparing to rupture and liberate the ovule. 



At the moment of dehiscence the ovule is thrown outward. 
The ovisac, abandoned by the ovary, becomes henceforth useless. 
Its role is completed. Blood and plastic lymph are effused into its 
interior. The place of rupture which has given passage to the 
ovule cicatrizes. The vesicle becomes folded on itself. From the 
transformations of its contents it takes on the appearance of the 
corpus luteum, disappearing by degrees until reduced to a linear or 
radiate cicatrix that is more or less depressed. The corpus luteum 
of menstruation differs from that of pregnancy only by the fact 
that the latter, under the influence of the activity impressed on all 
the genital zone by fecundation, instead of diminishing, enlarges 
for two or three months and does not undergo regression until after 
delivery. Thus we understand the phenomena of ovulation, there 



Menstruation and Fecundation. 21 

now remains to be studied the other condition of menstruation, that 
is, the flow of blood. 

The periodical haemorrhage that occurs during the genital life of 
woman generally begins, in France, at fifteen years of age and 
terminates at forty-five. Thus it may be said that the genital life 
continues about thirty years. But there are observed frequent 
variations in the period of appearance and of cessation of the 
menses, variations which depend upon the constitution, upon the 
temperament, upon the geographical latitude of the country, upon 
the education, upon the habitual diet, upon the race and upon the 
social condition of the woman. Various facts of precocious and of 
late menstruation have been cited. The menstrual flow is repro- 
duced in general every solar month (thirty to thirty- one days), 
sometimes oftener; every lunar month (twenty-eight days), and 
some women menstruate even every three weeks, others only every 
five weeks. Finally, there are some in whom the appearance of the 
flow is capricious and irregular. The duration of the flow is com- 
monly from three to six days. Some women only menstruate a few 
hours, others from ten to twelve days. I only give the extreme 
figures. It is difficult to appreciate the quantity of blood lost at each 
menstrual period, but a quantity less than fifty grammes or greater 
than five hundred grammes may be considered as pathological. 

The blood which flows during the menstrual period has its source 
in the tubes and in the body of the uterus, rarely in some other 
portion of the genital organs. Exceptionally the flow may occur 
from another region, in such cases as have been called menstrual 
deviation, where the periodical haemorrhage takes place from the 
lungs, from the intestine, from the mouth, from the nose, from the 
surface of a wound, from an erectile tumor or from the nipple. 

I return to the uterus. At each menstruation the uterine mucosa 
is folded on itself in such a way as to recall the cerebral convolutions. 
This tumefaction, the consequence of the genital congestion, favors 
the implantation of the fecundated ovule, which thus becomes 
grafted on the folds of the mucosa. The mucosa also undergoes 
other modifications, about which there are so many different 
opinions that it is impossible to judge of their true nature. 

Having sufficiently discussed the two essential phenomena of 
menstruation, there remains the study of their relations. Does the 
flow of blood depend upon ovulation? Or, on the contrary, does 
ovulation depend upon the blood-flow? Or, a third hypothesis, are 
these two factors independent? Each of these theories has its 
partisans. Without wishing to enter here into a complete discussion 
of this difficult question, I shall say that I believe in a certain de- ' 
gree of independence of ovulation and menstruation. I also believe 
that they are subordinate, one to the other, in such a way that they 
most often occur together. It is the union of ovulation and of 



22 Menstruation and Fecundation. 

menstruation that constitutes menstruation, as the current of air 
and the contraction of the vocal cords forms the voice. Now there 
is the same union and the same independence existing between the 
current of air and the contraction of the vocal cords, as between 
ovulation and the flow of blood. Ovulation is the essential phe- 
nomenon of menstruation and the sanguineous flow the accessory 
element. One assures fecundation, the other preparation for it. 
Their union place the woman in the most favorable condition for 
conception. From this study of menstruation we pass to that of 
fecundation or conception. 

Fecundation is the union of tw^o elements, male and female, in 
the aim of procreation of a new being. Conception is the synonym 
of fecundation, and only differs from it by a simple shade of 
meaning; fecundation indicating the union of the two procreative 
elements, and conception applying better to the state of the woman 
who has just been fecundated. We have spoken of one element, 
the ovule. We shall now turn to the spermatozoid. 

The spermatozoid, wrongly called spermatozoon at the time it 
was considered animalcule, is composed of a head of ovular form, 
measuring 5 mm. in its long axis, of a small cylindrical body of- 
fering almost the same length, and finally an undulating tail wdiich 
grows successively thinner toward its extremity, and has a length 
of 45 mm. From the recent studies on the development and 
the nature of the spermatozoid, it has been proven that it is only 
a cell of a particular form, the nucleus being represented by the 
head and the protoplasm by the intermediate segment. The tail is 
only a simple cilium analogous to that met in other cells of the 
economy. Under the microscope, in a drop of fresh spermatic fluid, 
spermatozoids are seen in great number, moving with great rapidity. 
These displacements are due to a corkscrew movement of the cilium 
wdiich constitutes the tail of the anatomical element. In a second 
a spermatozoid covers its length; it moves at the rate of two to 
three millimetres a minute. These movements quickly cease as 
soon as the spermatozoid is placed in an acid medium instead of 
the alkaline fluid in which it normally occurs. The uterine fluid 
being alkaline, and likewise that of the tube, the spermatozoid pre- 
serves its movements therein for a certain length of time, to fifteen 
days, according to Schroeder, and perhaps even more. But if there 
is endometritis, the uterine secretion becomes acid and the sperma- 
tozoid is quickly killed. 

The two elements, male and female, now being understood, we 
may essay the solution of the problem of fecundation, and to this 
end we shall note successively : The place of the meeting of these 
two elements; the approach of these elements, one toward the 
other ; the difficulties that they must overcome before union. 



Menstruation and Fecundation. 



•23 



At the moment of ovular dehiscence the ovule becomes free at 
the surface of the ovary, the spermatozoid, for the other part, is de- 
posited at the external orifice of the uterus as a consequence of 
coitus. To meet, the ovule and the spermatozoid must travel 
through the uterus and the tube. But the approach of these elements 
toward each other can only be comprehended by a previous study 
of the parts through which they must pass. We turn, then, to the 
cavities of the uterus and of the tubes. 




Head. 



Intermediate 
Segment. 



.Tail. 




0.025 



0.005 



0.025 



Fig. 4. — Spermatozoid. 



Fig. 5. — Uterus: 
body; isthmus; cer- 
vix. 



The uterine cavity is subdivided into that of the body and that of 
the cervix, which are separated by a short canal, the isthmus (Fig. 
5). Each of these cavities measure about two and one-half cen- 
timetres vertically, though in the nuUiparous woman the cavity of 
the cervix exceeds that of the body, and, on the contrary, in the 
multiparous woman that of the body is relatively greater. The 
cavity of the body has a triangular aspect, the superior angles being 
continuous with the tubes, and the inferior with the isthmus. The 
surfaces are plane and applied one to the other in such a way that 
the space is virtual or is filled in the normal state with a smaE 
quantity of mucus. 

The cavity of the cervix is fusiform, slightly flattened from before 
backward. The mucosa that lines its walls is uplifted by the 
arbor vitce, two in number. Each one of these structures is composed 
of a longitudinal axis, from which arise transverve and ascending 
branches. The anterior axis begins at the external orifice and is 
directed obliquely above and to the right ; the posterior axis, placed 
symmetrically to the origin of the former, followes an oblique path 
in an analogous direction, that is to the left and toward the internal 
orifice. The tv/o axes terminate by gradual diminution toward 



24 Menstruation and Fecundation. 

the isthmus, no branches existing at that place. The utility of the 
arbor vitse is unknown, but it is supposed that they favor the passage 
of the spermatozoids. 

The uterine cavity is lined by a mucosa, of one to two millimetres 
in thickness, continuous above with that of the tube and below with 
that of the cervix. In the cervical cavity the epithelium is calci- 
form, and is continued into the interior of the numerous racemose 
glands of this region. At the summit of the projections of the 
arbor vitse the epithelium becomes cylindrical and possesses cilia. 
In the isthmus and in the cavity of the body of the uterus, there is 
found cylindrical epithelium with cilia, that is prolonged into the 
interior of the tubular glands (with the exclusion of the cilia), the 
only variety contained in this region. 

The tube or oviduct is the canal that establishes communication 
between the surface of the ovary and the uterine cavity. When the 
abdominal cavity is opened, and the intestines are removed, there 
will be seen on each side of the uterus two transverse folds. These 
are the broad ligaments, the free or the superior border of which is 
divided into three wings. The anterior contains the round ligament, 
the median contains the tube, and the posterior is reserved for the 
ovary and its ligaments, to the number of two, one attaching it to the 
uterus (ligament of the ovary), the other to the tube (ligament of 
the tube). 

The tube presents an average length of twelve centimetres. De- 
parting from the supero-lateral angle of the uterus it takes a slightly 
tortuous course toward the lateral wall of the pelvis, terminating a 
short distance from this wall by expanding into a fringed and 
mobile pavilion. In the vicinity of the uterus the diameter of the 
tube is about one millimetre, and this increases more and more 
toward the pavilion. Its structure comprises a superficial, incom- 
plete, serous envelope ; a non-striated muscular tunic, composed of 
a superficial longitudinal layer and a deep circular; finally, the 
mucosa, which presents numerous longitudinal folds (Fig. 6). The 
epithelium which lines its cavity has cilia, as in the uterus, and 
at the free border of the tube it becomes directly continuous with 
the flattened epitheHum of the peritonaeum. This description is 
sufficient to give us a succinct idea of the canal, which extends from 
the ovary to the external orifice of the uterus, and which the two 
elements, male and female, follow in their approach toward each 
other. 

But a preliminary question occurs here, that of knowing at what 
place the meeting of the spermatozoid and ovule usually takes place. 
If it is possible to determine this point, we knoAv in advance the 
path taken by each of these elements. It has been shown from the 
experiments of Bischoif and of Nuck, on bitches, that the meeting 
takes place in the external third of the tube. Coste admits the same 



Menstruation and Fecundation. 25 

for the human female ; he also believes that if the meeting takes 
place nearer the uterus fecundation is not possible, for in pene- 
trating thus far the ovule becomes so coated with albumen as to 
become impermeable. 

Let us take the ovule at the surface of the ovary and the sperma- 
tozoid at the entrance of the uterus, and follow these elements to 
the point of meeting, in the external third of the tube, studying 
their mode of progression. 

We have four theories: One, of the progression of the spermatozoid 
by capillary action (Coste, hoiegeois) ; one, as to the action of the 
vibratile cilia (Muller) ; another, as to the movement of aspiration 
made by the uterus at the end of coition (Eiolan, Morgan), and a 
fourth, a supposition that the spermatozoids are capable of inde- 
pendent migration by virtue of the rapid progression revealed 
under the microscope. Thus we are in the presence of four theories 
that render quite plain the progress of the spermatozoid. It has 
been objected that ciliated cells do not exist in the whole extent of 
the genital organs ; that aspiration cannot be exerted in a cancerous 
uterus ; that in certain animals fecundation is possible although 
the spermatozoids are not mobile. These are simple objections of 
detail w^hich show us that 'one of these causes may be deficient or 
absent without impeding fecundation. It appears rational to admit 
that capillary action, the vibratile cilia, uterine aspiration and 
the movements of the spermatozoids are conjoined in aiding the 
progress of the male element in the interior of the female genital 
organs. All these theories are true in part, but no one of them 
should be admitted to the exclusion of the rest. 

With regard to the ovule, the problem to be solved is the manner 
in which it passes from the surface of the ovary to the external 
third of the tube. The distance is short and yet the difficulty is 
great, for the route is not continuous. The surface of the ovary, 
like the pavilion of the tube, floats in the great peritoneeal cavity. 
The ovule then passes from one to the other, much as a projectile 
is thrown from one point to another in the atmosphere. Attempts 
have been made to explain this migration in five different w^ays : 

1. Heller and Eouget believe that, at the moment of dehiscence of 
an ovisac, the pavilion of the tube, free in the usual state, applies 
itself on the ovary and exactly encloses it. The ovule is thus en- 
grossed and gathered into the tube at its issue from the ovisac. 

2. Kehrer advances the theory of the projection of the ovule into 
the pavilion of the tube by an impulse given it from the bursting 
of the Graaffian follicle. I do not believe in this fantastic theory. 

3. The ligament which unites the ovary to the pavilion is slightly 
hollowed out on its upper surface in the form of a trough ; Henle 
interprets this anatomical disposition by giving us the opinion that 
the ovule follows this from the ovary to the tube. 4. But little 



26 



Menstruation and Fecundation. 



satisfied with the explanations given, and discouraged in his vain 
researches, Kiwisch has advanced the idea that the migration of 
the ovule is accidental. The peritonaeum thus becomes the tomb 
of useless ovules. 5. I arrive at the theory of the menstrual lake, 
that I have reserved for the end, as it appears the most adapted to 
explain the migration of the ovule. 




Fig. 6.— Uterus. Tube. Ovary. 




Fig. 7. — Posterior round ligament. I, ligament of the ovary; 2, ligament of the 
tube; 3, posterior round ligament, with the three branches external, median, internal. 

According to Becker, at the moment of dehicence there occurs 
around the ovary an accumulation of seru??^ and liquid blood which 
constitutes a veritable lake. When the ovule leaves the ovisac it 
floats on this fluid, which, being diverted by the tube into the uterus 
draws the ovaule with it into the genital canal. But an objection 
arises at once. If this current draws the ovule from the ovary 
toward the vulva, how can the spermatozoid, placed under the same 
influence, pursue a contrary direction? I shall remark that the 
spermatozoid is generally deposited in the feminine genital organs 
before or after the flow, and that it gains the external tliird of the 
tube without undergoing the influence of this current. I know that 



Development and Description of the Human Ovum. 27 

some conceptions only take place on condition of a coitus during 
the menstrual period. But these exceptions may be explained by 
admitting that the spermatic fluid, from its special consistence, 
remains adherent to the uterine mucosa, or even to the vaginal, and 
that it accomplishes fecundation after cessation of the menstrual 
flow. We might also suppose that by the action of the vibratile 
cilia and the movements of the spermatozoids, the male element is 
capable of overcoming the sero- sanguineous current to arrive at the 
ovule. 

The ovule and the spermatozoid having met in the external third 
of the tube, fecundation occurs, the woman has conceived and 
pregnancy commences. We are now to study all the transforma- 
tions of this fecundated ovule, which becomes the embryo, and then 
the foetus, and all the modifications affecting the material organism 
under this influence. 



CHAPTER II. 



DEVELOPMENT AND DESCRIPTION OF THE 

HUMAN OVUM.* 

The fecundated ovule in the external third of the tube continues 
in its course toward the cavity of the body of the uterus, where it 
arrives in a few days, and where it becomes fixed and develops 
during the nine months of pregnancy. During this passage the 
ovule begins its transformation and continues in development after 
its arrival in the uterus. The modifications to be disclosed begin, 
then, in the tube, and are achieved after fixation in the uterine 
cavity. In studying fecundation, we left the ovule surrounded by 
spermatozoids. We will then take up the description at the same 
point. The first transformations to which fecundation gives rise are : 

1. The formation of the male nucleus. 

2. The fusion of the two nuclei, male and female. 

3. Segmentation. 

4. The formation of somatopleures and of splanchnopleures. 

1. Formation of the male nucleus. — Spermatozoids in variable 
number surround the ovule and attempt to penetrate the vitelline 

* I omit some modifications of the ovule previous to fecundation (formation of the 
amphiaster, emission of polar globules), which are of secondary importance. 



28 Development and Description of the Human Ovam, 

membrane in the endeavor to traverse the vitellus to the germi- 
native spot, which is only the nucleus of the ovule, represented in 
Fig. 8 by the central black spot. One of these spermatozoids, 
either because it is endowed with a particular vigor, or because it 
finds a thin and relatively weak point in the vitelline envelope, 
buries itself in the surface of the ovule. At its approach the vitellus 
form a projection to meet it, as if to invite it to enter, and draws 
it tow^ard the centre. To this momentary projection of the vitellus 
has been given the name "cone of attraction." The spermatozoid, 
as indicated in Fig. 9, which represents the successive, steps of 
the penetration, continues to approach the center. Soon the head 
becomes detached from the intermediary segment and from the 
tail, the role of which is terminated and which quickly disappear. 
In the interior of the ovule there are now found two nuclei (Fig. 
10) ; one, the larger, is the germinative vesicle — the female nu- 
cleus of the ovule ; the other, placed between the preceding and 
the vitelline membrane, is the male nucleus, the former head of the 
spermatozoid. 

2. Fusion of the two nuclei, — The male nucleus becomes sur- 
rounded by a series of small rays which cover all its surface like 
bristles (Fig. 11). Continuing its concentric progress, this nucleus 
arrives in contact with the female nucleus (Fig. 12), with which it 
becomes fused little by little, furnishing a series of appearances 
which recall, somewhat, two stars passing over the other as in 
eclipse. In Figure 13 the eclipse is total, the fusion of the two 
nuclei complete. The ovule presents the same details as before 
fecundation, the vitelline membrane, the vitellus, the germinative 
vesicle or nucleus, in which exists the germinative spot or nucle- 
olius. But the male nucleus, essentially active, has been added to 
the female nucleus, which passively awaited it, and has imparted 
to the ovule a new vitality, the effects of which are quickly per- 
ceived. 

3. Segmentation, — The ovular nucleus is seen to divide and give 
birth within the vitelline membrane to two distinct cells (Fig. 14) . 
The segmentation continues, in place of tAvo cells, four appear (Fig. 
15). Finally, by a series of analogous divisions (Fig. 16) a great 
number of cells accumulate in the interior of the ovule, contained 
within the vitelline membrane. We are now at about the eighth day 
consecutive to fecundation. 

4. Formation of somatopleures and splanchnopleures. — In the center 
of this agglomeration of cells is formed a small collection of liquid 
which by its progressive augmentation pushes back the cells 
eccentrically and packs them into the vicinity of tha vitelline wall 
(Fig. 17). All these cells, which as a whole constitute the blasto- 
derm, are divided into three distinct layers (Fig. 18). The ex- 
ternal, or ectoderm; the middle, or mesoderm, and internal, or 



Development and Description of the Human Ovum, 29 





Fig. 8. — Meeting of the spermatozoids 
and the ovule. 



Fig. 9. — Penetration of the spermatozoid. 





Fig. 10. — Ovule, with its two nuclei, FiG. II, — Radiations of the male nucleus, 
male and female. 





Fig. 12. — Approach of the two nuclei. Fig. 13. — Fusion of the two nuclei. 



30 



Development and Description of the Human Ovum, 



endoderm. The three layers, external, middle and internal, of the 
blastoderm are also called epiblast, mesoblast and hypoblast re- 
spectively. 





Fig. 14.— Segmentation. 



Fig. 15. — Segmentation. 




Fig. 16. — Segmentation. 




Liquid collection pushing 
the cells excentrically. 



Fig. 17. — Peripheral accumulation of the cells. 



Development and Description of the Human Ovum. 31 

This division does not take place posteriorly, where the cells 
remain packed together, and there they soon are separated by a 
canal, which becomes the medullary canal, and by a thickening, 
circular on section, called the dorsal cord or the notochord, which 
forms the bodies of the vertebrae, that is, the most resistant part of 
the vertebral column. The section of this dorsal chord and medul- 
lary canal can be seen in Fig. 19. 

The same illustration indicates a new transformation of the ovule- 
The mesoderm, or the middle layer of the blastoderm, is separated 
into two rows of cells, the external adhering to the ectoderm and 
the internal to the endoderm. By this separation the three layers 
now form only two : 

An external, called the somatopleure. 

An internal, called the splanchnopleure. The somatopleure forms 
the envelope and the framework of the body, the splanchnopleure, 
the viscera. 

To facilitate the comprehension of the preceding illustration, 
the two layers, formed by cells composing the splanchnopleure and 
the somatopleure, will be represented by a unique character as 
shown in Fig. 20, which is otherwise identical with Fig. 19. 

These two layers are blended behind in a common mass in 
which is perceived the dorsal cord and the medullary canal. The 
somatopleure and the splanchnopleure, which were disposed in a 
circular manner (Fig. 20), next undergo a strangulation in their 
middle portion as indicated in Fig. 21. This strangulation divides 
these two membranes into two distinct regions : 

One. embryonic (inferior, Fig. 21). 
The other, extra-embryonic (superior). 

The embryonic portion is united to the extra- embryonic by the 
intermediate or constricted region. Now these three parts have, in 
the ulterior development of the ovum, different roles to fulfill. 

The extra- embryonic part will form the envelopes of the ovum and 
the placenta. 

The intermediate part will form the cord. 

The embryonic part will form the foetus. 

Let us study successively the development of each of these parts 
and their constitution after complete formation. 

I. Extra- embryonic portion of the ovum. — Membranes. — 
Placenta. — Amniotic liquor. — The extra -embryonic part of the ovum 
is formed, as we have seen in Fig. 21, by the extra-embryonic 
somatopleure and splanchnopleure, separated by a virtual space 
called the external coelum (the internal coelum is an analogous space 
found at the embryonic part). The real cavity formed by the 



32 Development and Description of the Human Ovum, 

extra- embryonic splanclinopleure is called the umbilical vesicle and 
contains the elements for the nutrition of the o\aim until the for- 
mation of the placenta. This umbilical vesicle corresponds, as to 
its contents, to the yolk of the eggs of birds. While the wall of the 
umbilical vesicle, formed by the splanchnopleure, undergoes an- 
atrophy and a progressive retreat, the suprajacent layer, on the 
contrary, which is only the extra-embryonic somatopleure, takes on 
a considerable and rapid development to constitute the secondary 
chorion and the amnion. The layer of the somatopleure, is seen to 
throw out a series of prolongations, indicated by the successive 
tracings 1, 2, 3, 4 (Fig. 22). These prolongations meet one another 
by surrounding the ovule ; their reunion quickly occurs at a point 
opposite to their origin. When this reunion is achieved (Fig. 23), i. e., 
of the two layers created by this prolongation, one is directly applied 
to the internal surface of the vitelline membrane over all its extent ; 
the other, continuing with the intermediate somatopleure, lines a 
part of the external surface of the umbilical and of the internal 
surface of the preceding layer; while between them and the 
embryo exists an actual cavity in which is collected the amniotic 
fluid. 



_ Endoderm. Hypoblast. Internal layer. 
Mesoderm, Mesoblast. Middle layer. 

Ectoderm. Epiblast. External layer. 
Vitelline membrane. 




Fig. i8. — Formation of the three blastodermic layers. 

The primary chorion is formed by the vitelline membrane, 
the surface of which is covered at a certain time with villi. The 
secondary chorion is created by the addition of the layer of the extra- 
embryonal somatopleure to the vitelline membrane. These two 
membranes undergo a true fusion to form the secondary chorion. The 
membrane which, in Fig. 23, is found under the secondary chorion, 
is the amnion. In the space which separates them is developed the 
definitive chorion, as we shall see. 



Development and Description of the Human Ovum. 33 




- 4 



Fig. 19. — Formation of somatopleure and splanchnopleure. i,splanchnopleure; 
2, somatopleure; 3, dorsal cord; 4, medullary canal. 




Fig. 20. — Simplification of Fig. 19. i, chorial villi; 2, vitelline membrane; 
3, somatopleure; 4, splanchnopleure. 

From the embryo, between the somatopleure and the splanchno- 
pleure, in the pelvic region, is developed a hollow bud, which pro- 
gressively enlarges separating the two limiting membranes, this is 



34 



Development and Description of the Human Ovum, 



the allantois. Its embryonic part becomes the bladder and the 
nrachus and its extra-embryonic part forms the third chorion (or 
definitive) and the placenta. Fig. 24 shows the first steps of the 
development of the allantois. Fig. 25 defines a more advanced 
stage. The allantois progressively invades the space which separates 
the secondary chorion from the amnion. It may be compared to 
an umbrella, the handle forming the cord and the spread portion 
extending more and more to envelope the embryo as in 1, 2, 3, 4 (Fig. 
25). We are now at about thet wenty-fifth day consecutive to the 
fecundation. 

Chorial villi. 
Vitelline membrane. 

Somatopleure. 

Splanchnopleure. 
Extra-embryonicpart 

External coelom. 



Intermediate part of 
the ovum. 



Embryonic part of the 

ovum 
Somatopleure. 
splanchnopleure. 

Internal coelom. 



Fig 21. — Strangulation of the ovum. 

At the end of the first month the allantois is at the height of its 
development. It has carried with it, over all the internal surface of 
the secondary chorion, vascular ramifications, which are prolonged 
into the villi. The umbilical vesicle, after the absorption of its 
contents for the development of the ovule, progressively atrophies. 

During all the second month the enveloping membranes change 
but little, they undergo a development as a whole, all their surface 
is covered by vascular villi, so that the shaggy ends of these 
structures can be easily seen by floating the ovum in water. 

During the third month, the villi which cover the surface of the 
ovum atrophy except at the point where the ovum adheres to the 
uterus and there they take on a remarkable development. This 
hypertrophied region, where all the life of the allantois seems local- 
ized, becomes the placenta ; over all the rest of its extent the allantois 
atrophies, as indicated in Fig. 26. 




Development and Description of the Human Ovum. 35 

Outside the placental zone the allantois is entirely united to the 
secondary chorion, as indicated in a limited region of Fig. 26; 
thus is formed the tertiary or definitive chorion. Thus it is seen 
that the primary chorion is formed by the vitelline membrane, the 
secondary by the extra-embryonic somatopleure ; the tertiary by the 
allantois. 




Fig. 22. — Prolongations of the extra-embryonic somatopleure. 

The umbilical vesicle continues to atrophy. This atrophy is 
complete at the end of the third month, and at this moment 
nutrition by the placenta is definitely substituted. Consequently at 
this time the embryo becomes the foetus ; that is, at the end of the 
third month, or at the commencement of the fourth, the reign of 
the allantois, i. e., the placenta, replaces that of the umbilical vesicle. 
This vesicle atrophies so completely that it is difficult to find traces 
of it in the ovum at term. 

The ovum during the evolution that we have now to follow, is en- 
closed and protected by the uterine mucosa, which takes a special 
evolution transforming it into a new membrane called the decidua, 
thus designated because it is destined to being cast off at the same 
time with the ovum. 

The preceding description has given us a summary of the for- 
mation of the placenta, of the chorion, of the amnion, of the decidua 



36 



Development and Description of the Human Ovum. 



and of the amniotic fluid ; we have now to study the details, which 
will initiate us more intimately into the constitution of these dif- 
ferent parts, by taking as a type the ovum nearly arrived at term. 
But before beginning this detailed description, it is indispensable to 
embrace at a glance the general configuration of the ovum enclosed 
by the uterus. The schematic section represented by Fig. 27 
permits us to easily grasp this as a whole. 




Fig. 23. — Formation of the amnion and secondary chorin. i, vitelline membrane 
or primitive chorion : 2, umbilical vesicle; 3, secondary chorion; 4, amnion; 5, amni- 
otic cavity containing the amniotic liquid. 

Here there is seen, in passing from the uterus to the foetus : 

1. The uterine wall, thin in the inferior segment at the cervix. 

2. The uterine mucosa (partially transformed into the decidua), 
considerably thickened at the placenta and divided in the rest of 
its extent into two layers, one applied directly on the ovum (ovuline 
decidua), the other to the inner surface of the uterus (uterine de- 
cidua) ; the latter is continuous inferiorly with the cervical mucosa. 
We shall study later the formation of these membranes. 

3. The chorion, considerably hypertrophied in one region to con- 
stitute the placenta, and atrophied, on the contrary, in the rest of 
its extent, where it is enclosed between the ovuline decidua and the 
amnion. 



Development and Description of the Human Ovum. 



37 



4. The amnion, which is the most internal membrane. 

5. The amniotic fluid, which fills the cavity of the amnion, and 
in which floats the foetus connected to the placenta by the cord. 




Fig. 24.— Formation of the allantoic bud. i, progression of the allantoic 

bud ; 2, allantoic bud. 

We shall study these different parts in the following order: I. 
Placenta. II. Chorion. III. Amnion. IV. Decidual membranes. 
V. Liquor amnii. 



I. Placenta. — The placenta, forming the union between the 
maternal and foetal circulations, is a fleshy and vascular disc, termi- 
nating by one of its surfaces in the cord, the other adhering to the 
internal wall of the uterus. Its weight is about five hundred 
grammes, nearly that of the liquor amnii, so that the foetal append- 
ages represent approximately a kilogramme. Dimensions : twenty 
centimetres in diameter or a little less ; three centimetres in thick- 
ness toward the center, pressively thin toward the edge. To under- 
stand this organ completely it is necessary to study : 1. Its foetal 
surface ; 2. Its uterine surface ; 3. Its circumference ; 4. Its 
structure; 5. Its physiology. 

1. ^\iQ foetal surface y in contact with the liquor amnii, is smooth 



38 



Develoj^ment and DescriiJtion of the Human Ovum, 



in all its extent, for it is covered by the amnion, which can easily 
be detached. It is grooved by the vessels formed by the expansion 
of fmiicular arteries and veins. 




Fig. 25. — Development of the allantois. i, secondary chorion (the two 
membranes being united in one). 

The insertion of the cord may occur in four different regions 
(Fig. 29) : 

1. At the center of the placenta (central insertion). 

2. Between the center and the periphery (lateral insertion). 

3. At the margin of the placenta (marginal insertion). 

4. On the membranes (velamentous insertion). 
Their relative frequency is as follows : 

Central and lateral insertion (equally frequent) 95 per 100. 
Marginal insertion 4 per 100. 
Velamentous insertion 1 per 100. ♦ 

In cases of velamentous insertion, which may occur up to twenty 
centimetres from the placental margin, the^^essels may ramify in 
the membranes (Benckiser), or, on the contrary, they may pursue 
isolated courses up to the placenta before dividing (Lob stein). 

2. The uterine surface is unequally projecting and fiocculent, and 
divided into lobes or cotyledons by a number of more or less marked 



Development and Description of the Human Ovum. 



39 



grooves. These lobes, to the number of ten, fourteen, or more, are 
divided into lobules, which are composed by a grouping of villi. It 
is by this surface that the placenta is adherent to the uterus. To 
state this insertion exactly, it is important to divide the internal 
surface of the uterus by two parallel plans AB, CD (Fig. 31) pass- 
ing one at eight centimetres below the fundus of the uterus, the 
other at eight centimetres from the internal orifice. According 
to a series of measurements that I have made, it results that the 
distance which separates the two planes AB and CD, by following 
the uteiine wall, is about sixteen centimetres. 




Fig. 26,— Formation of the placenta and tertiary or definite chorion, i, remains of 
the umbilical vesicle; 2, tertiary or definite chorion; 3, placental villi ; 4, placenta; 
5, allantois. 

Every placenta which by any part of its surface is inserted below 
the plane CD, that is to say which encroaches on the uterine circle 
blended with plane CD, is an inferior polar placenta, or a idacenta 
prcevia. 

Likewise, every placenta which by any portion of its extent is in- 
serted above the plane AB is a superior polar placenta. 

Every placenta inserted between these two planes may be called 



40 



Development and Description of the Human Ovum, 



equatorial, for its center coincides with the equator of the uterus, 
but this variety is rare, the diameter of the placenta being usually 
greater than sixteen centimetres and thus encroaching on one of 
the polar circles. From the statistics of forty-eight cases I ha^e 
found : 

Inferior polar placenta in one-third of the cases. 

Superior polar placenta in two- thirds of the cases. 

Equatorial placenta, exceptionally. 
The inferior polar placenta, or placenta praevia, gives rise to a 
series of accidents which will be studied later. 




Fig. 27. — Ovum definitely formed, i , remains of the umbilical vesicle ; 2, maternal 
placenta; 3, foetal placenta; 4, cord; 5, amnion; 6, chorion; 7, ovuline decidua; 
8, decidua and uterine mucosa; 9, uterine wall. 

3. The circumference of the placenta is constituted by the union 
of the membranes with this organ. This placental margin, regular 
in a rounded or oval placenta, becomes more or less tortuous when 



Development and Description of the Human Ovum. 



41 




Fig. 28.— FcEtal surface of the placenta, with amnion partly uplifted. 




Fig. 29. 




Fig. 30.— Uterine surface of the placenta. 



42 



Development and Description of the Human Ovum. 



the form departs from the normal type. Thus we are led to say a 
few words on the different forms of placenta m simple pregnancy : 

A. Sometimes the placenta is unilobed, the most frequent form. 

B. Sometimes it is multilobed, but not having the lobes entirely 
separated. 

C. Sometimes it is multilobed, with the lobes so distinct that 
there appear to be several placentas. 




Fig. 31. 



As examples of these varieties we have under 
A. Unilobed placenta. 




Fig. 32. 



1. Circular form (Fig. 32). 



Development and Description of the Human Ovum, 43 




2. Oval form (Fig. 33). 



Fig. 33. 




Fig. 34. 



3. Irregular form (Fig. 34). 



44 Development and Description of the Human Ovum. 

B. United multilohed placenta. 




Fig. 35. 



1. Two equal lobes (Fig. 35). 




Fig. 36. 
2. Two unequal lobes (Fig. 36). 



Development and Description of the Human Ovum. 45 




Fig. 37. 
3. There exist more than two lobes (Fig. 37). 



C. Placenta ivith separate lobes. 




Fig. 38. 
(a). Two equal lobes (Fig. 38). 



46 



Development and Description of the Human Ovum, 




Fig. 39. 
(b). Two unequal lobes (Fig. 39). 




Fig. 40. 
(c). More than two lobes (Fig. 40). 

4. Structure. — Let us take a perpendicular section of the uterine 
wall, the placenta, and the cord, as represented in the schematic 
illustration of Fig. 41. We then find, from the superficies toward 
the center : 

1. Beneath the peritonaeum (which is not given in the illustration) 
the muscular wall. 

2. Beneath the uterine mucosa, transformed into the maternal 
placenta containing a series of lacunar spaces, the remains of the 
glandular culs-de-sac more or less modified and terminating super- 
ficially in a series of villi. 

3. ^h.Q foetal placenta, shaggy on the uterine side, by virtue of its 
rich mass of villi interlacing with those of the maternal placenta; 
smooth on the foetal side, where it is in contact with the amnion. 



Development and Description of the Human Ovum, 47 

4. Finally , iiie umbilical cord. 

Through all these tissues is found a vascular network, the details 
of which I shall give after having explained at greater length these 
different parts. 




Arcular venous sinus (maternal 
placenta). 



Vein of maternal placenta. 



—Sinus. 



Sinus. 
Funicular artery. 



Cord. 

Funicular vein. 
An isolated villus. 

Sinus. 
Villus of foetal placenta. 

Villus of maternal placenta. 

Maternal placenta. 
Glandular opening. 

Amnion. 
■Chorion. 
Ovuline decidua. 

Uterine decidua. 



Fig. 41. — Schema representing the structure of the placenta. 

A. Maternal placenta. — The uterine mucosa, transformed in the 
placental region, is divided into two parts, separated by the more or 
less regular line of the glandular lacunae. It is at this place that 
separation occurs at delivery, the eccentric part remaining adherent 
to the uterus to constitute the new mucosa, the other portion, the 
decidual, follows the placenta. When we examine the uterine 



48 Development and Description of the Human Ovum. 

surface of a recently-expelled placenta, it is the portion corre- 
sponding to this series of lacunae that meets our eyes. The part 
near the foetal placenta terminates in series of villi, somewhat 
projecting and ramifying. In a vascular point of view, these villi 
are of two kinds, as will be seen in Fig. 41. In one variety the 
artery is continuous with the vein after having formedd a more 
or less rich vascular network. In another the artery opens directly 
by one or two orifices into spaces called sinuses. From these villi 
arise other veins. In this way the blood returns into the venous 
system and enters the uterine sinuses directly or by the interme- 
diate circular sinus wiiicli exist around the placenta. 

B. Fa'tal placenta, — The framework of the foetal placenta is 
formed, like that of the maternal, of connective tissue, with fusi- 
form and star-shaped cells. It is adherent by its foetal surface to 
the chorion, of which it is only the expansion, and is united to the 
maternal placenta by a series of rich and luxurious villi. The villi 
are of two kinds : one absolutely free, floating without adhesions in 
the sinuses, the other terminating by the extremity in the maternal 
placenta. These villi are furnished with vessels in the form of a 
capillary network with an apparent artery and an afferent vein. 

From the preceding description it is seen that the union of the 
two placentas, foetal and maternal, occurs through the intermediate 
villi. Some of the maternal and foetal villi are in contact, and some 
are separated by the blood of the sinus which surrounds them like 
an atmosphere. The blood of these sinuses is exclusively maternal. 
There is no direct communication between the blood of the mother 
and that of the foetus, but a simple mediate contact, through the 
flattened epithelium which forms a continuous layer at the surface 
of the villi, and through the walls of the vessels. The physiological 
changes which we have now to study occur through the medium of 
this barrier. 

5. Physiology. — In the placenta, the foetal and the maternal blood 
being in mediate contact, the foetal blood is relieved of its carbonic 
acid and absorbs oxygen, just as this occurs in the lungs of an 
adult. Thus a veritable respiration takes place at this point. 
Besides this, the nutritive elements contained in the maternal 
blood are absorbed by the foetal blood, so that the placenta plays 
a double role, respiratory and nutritive, taking the place, for the 
foetus, of the lungs and of the digestive tract. Aside from the 
normal constituents carried by the maternal blood, there may be 
abnormal elements, such as the different medicaments and divers 
microbes. The iodide and chlorate of potash and salycilic acid 
ingested by the mother during labor are found after birth in the 
foetal organism. The same is true of potassium nitrate, of yellow 
prussiate of potash, of bromide of potassium and sulphate of quinine, 
but their passage is slower. Chloroform also passes from the 



Development and Description of the Human Ovum. 49 

mother to the fcetus, but without danger to the child. Solid 
elements may pass through the placenta. The transmission of 
microbes has been recently established. The majority of the 
pathogenetic microbes traverse the placenta but with unequal 
facility. However, the placenta is not a simple filter, it also 
possesses the power of producing sugar ; the glycogenic function 
identical with that pertaining to the adult liver. The placenta not 
only serves the foetus as a digestive tube and lung, but also takes 
the part of the hepatic gland. 

II. The Chorion. — This simple name is given to the tertiary 
or definitive chorion. Situated between the decidua, which covers 
its external surface, and the amnion, which lines its internal 
surface, it is more adherent to the first than to the second. The 
adhesion with the decidua is immediate, that with the amnion is. 
mediate and occurs through an intermediate glutinous substance, 
the reticulated magma. This disposition explains why the amnion 
is so easily detached from the chorion during labor, while detach- 
ment of the chorion from the decidua is rarely observed ; and why 
the liquor amnii, transuding through the amnion, so easily accumu- 
lates between this membrane and the chorion. 

The chorion is composed of a stroma of connective tissue. Its 
external surface is covered by a layer of pavement cells, with which 
it is in contact with the decidua. Eich in vessels at the second 
month of gestation, it is completely deprived of them after the 
<)omplete and definitive formation of the placenta; however, ex- 
ceptionally these vessels may persist. 

III. Amnion. — The amnion is the most internal membrane of 
ihe ovum. After having covered alb the internal surface of the 
ovum it is continued on the placenta and then to the cord, which 
it surrounds like a sheath, terminating at the umbilicus, where the 
cutaneous covering of the foetus begins. The amnion is composed 
of two layers ; an external, containing connective tissue with some 
non-striated muscular fibres, and an internal, or epithelial, directly 
in contact with the liquor amnii. Vessels are wanting, except in 
the vicinity of the placenta, where during the first months of preg- 
nancy are met the vasa propria which secrete the amniotic liquor, 
and the abnormal persistence of which would be one of the causes 
of hydr amnios. 

IV. Decidual Membranes. — The decidual membranes being 
formed at the expense of the uterine mucosa, are then of maternal 
origin. I shall describe them here, however, because their union with 
fhe ovum is so intimate, and because, as their name indicates, they 
are cast off with it. The decidual membranes are three in number, 



50 



Development and Description of the Human Ovum. 



the utero-placental, the uterhie, and the ovuHne. How are these 
decidual membranes formed ? On the arrival of Ihe ovum in the 
uterine cavity it lodges in the mucous folds as indicated in Fig. 
42. The two projections of the mucosa, which limit the fold in 
which the ovule reposes, take on a rapid development and surround 
the ovule more and more (Fig. 43). Soon they enclose it com- 
pletely, as in Fig. 41. At this moment there exist three distinct 
parts : The first is formed by the union between the ovum and the 
uterine wall; this is the utero-placental decidua, formerly called 
the serotrine decidua. The second lines the uterine wall and only 
undergoes slight modifications ; this is the uterine or true decidua. 
The third directly covers tha ovum, by means of the development 
already described; this is the ovuline decidua or decidua reflexa. 






Fig. 42. 



Fig. 43. Fig. 44. 

Enclosure of the ovum by the uterine mucosa. 




Fig. 45. — Disposition of the deciduas in relation to the ovum and uterine wall. I, 
placenta; 2, uterine wall; 3, uterine decidua; 4, ovuline decidua; 5, ovum. 

These three decidual membranes being known, let us follow their 
evolution. During the first three months of pregnancy, the ovuline 



Development and Description of the Human Ovum. 



51 



and the uterine clecicluas are separated by a space, which permits 
the passage of the spermatozoids to the tube and a second fecun- 
dation after the first. These facts will be studied later under 
super-fecundation. With the second three months the conditions 
change, the ovuline and the uterine deciduas are in contact and 
quickly contract intimate adhesions in such a manner (Fig. 45) 
that the uterine wall is fused with the ovum; thus, at this 
moment, super-fecundation becomes impossible unless a double 
uterus exists. It is likewise understood why abortion during the 
second three months is so often accompanied by the retention of 
membranes and especially of the decidua. 



Uterine muscle. 



Glandular 
culs-de-sac. 



Spindle-shaped 

cells. 



Round cells. 

Chorion. 
Amnion. 




Robin. 



Sinety. 



Friedlander. 



Fig. 46. — Section of the internal wall and of the membranes. 

During the last three months, separation from the ovum and 
from the uterine wall is progressive. As for the placenta separation 
occurs at the moment of delivery at the level of the glandular culs- 
de-sac. As to the membranes, opinions differ. To comprehend 
the place where separation occurs, let us follow (Fig, 46) the 
different layers met in going from the uterus to the liquor amnii. 
Beneath the peritonaeum, not represented in the illustration, is found 
the uterine muscle, then the mucosa and the united deciduas in 
three layers ; the first lamina strewn with glandular culs-de-sac, the 
second composed of elongated cells, the third of round cells. 



52 



Develojwient and Description of the Human Ovwn. 



Concentrically are the chorion and the amnion. Now, the sepa- 
ration occurs : 

According to Eobin, at the union of the muscle with the mucosa, 
which thus is cast off as a whole, leaving the uterine wall naked. 

According to Sinety, at the level of the glandular culs-de-sac, the 
same as the placenta. 

According to Friedlander, in the middle of the layer of elongated 
cells. 




Fig. 47. — Evolution of the ovuline and uterine deciduas. i, glandular culs de- 
sac; 2, placenta; 3, uterine wall; 4, ovum; 5, uterine decidua; 6, membrane of new 
formation covering the non-decidous mucosa; 7, nondecidous uterine mucosa; 8, 
ovuline decidua.; 9, cervix; 10, mucosa of the cervix. 



With regard to the decidua, the opinion of Sinety appears the 
most admissible. For the membranes as for the placenta separation 
occurs at the level of the glandular culs-de-sac, the superficial 
portion of the uterine decidua remaining adherent to the ovuline 
decidua (Fig. 47) and thus only this superficial i^ortion is cast off 
with the foetus. At the moment of term, the detachment, which 
commences in the vicinity of the internal orifice, and gains the 
fundus by degrees, is usually complete or at least very extended. 



Development and Description of the Human Ovimi. '53 

V. Liquor Amnii. — The amniotic fluid appears a little after the 
formation of the amnion. At four months and a half its weight is 
equal to that of the fcetus. At term it amounts, on the average, 
to half a litre. However, there are very extensive variations. But 
when the quantity exceeds a litre there results the pathological 
state known as hydramnios, a question belonging to puerperal 
pathology. Clear and transparent in the beginning of pregnancy, 
slightly yellow at the end, in the pathological state it may become 
greenish or red. This liquid, in which is found some elements 
proceeding from the epidermis of the foetus, from the renal and 
from the amniotic epithelium, contains chiefly chloride of sodium, 
lactate of sodium and albumin. 

The origin of the liquor amnii is not yet definitely settled. Some 
suppose that it proceeds from the mother, by filtration through the 
membranes into the amniotic cavity. Others believe it to proceed 
from the ovum, arising from the annexes, from the vasa proj^riaof 
Jungbluth, from the cord, or from the foetus itself by renal and 
cutaneous secretions. 

Physiology. — The uses of the amniotic liquid are multiple. By 
its presence it creates a veritable liquid atmosphere for the foetus. 
If the uterine walbwas applied on the foetus, funicular circulation 
would certainly be impossible. During labor, the liquor amnii 
accumulating in the bag of waters, favors the opening of the genital 
canal. 

II. Intermediate portion of the ovum. — The cord, — The 
umbilical cord is the flexible stem which joins the placenta to the 
foetus. We have already seen its formation. 




Fig. 48,~Straight cord. 




Fig. 49.— Twisted cord. 

External conformation. ^^mooth and whitish at its superficies, 
the cord sometimes represents a plain stem (Fig. 48), sometimes, 
on the contrary, a stem twisted on itself, and this tortion may be 
directed from right to left (Fig. 49), or from left to right. Some- 
times on the same cord a torsion in an inverse direction is noted 
at the two extremities. The relative frequency of the different 
varieties of funicular torsion (the spiral will be described by follow- 
ing the cord from below upward) may be indicated by the following 
figures : 



54 



Development and Description of the Hu77ian Ovum, 



Sinistro-torsion, 72 per 100. 
Dextro-torsion, 25 per 100. 
Double torsion, 1 per 100. 
No torsion, 2 per 100. 

The torsion of the cord is due to the disposition of the vessels, 
which will be studied later. 





Fig. 50. — Circular nodosity. 



Fig. 51. — Sessile and pedunculated 
nodosities, i, pedunculated nodosity; 
2, sessile nodosity. 



The usual length is fifty centimetres at term. Variations : maxi- 
mum, one metre, seventy-eight centimetres (Neugebauer) ; mini- 
mum, total absence, where the umbilicus is adherent to the placenta. 
The size is nearly that of the little finger. Variations : maximum, 
seven centimetres and one-half in circumference (Bell) ; minimum, 
the size of a goose quill (Scanzoni). Much more marked restrictions 
may exist and compromise the circulation. On the cord are often 
found nodules, that may be circular (Fig. 50), sessile or peduncu- 
lated (Fig. 51). The contents of these nodules may be gelatinous 
(Wharton's jelly), arterial (vascular loop), or venous (venous loop 
or venous dilatation). With these nodules, or simple swellings of 
the cord, there must not be confused the true knots, which will be 
studied under pathology. The insertion of the cord takes place for 
one part at the umbilicus and for the other part at the internal 
surface of the placenta. The latter insertion has been fully 
described. 

Interior conformation. — AVhen the cord is cut transversely, it is 
found composed (Fig. 52) of a continuous amniotic envelope, filled 



Development and Description of the Human Ovum, 



55 



and distended by Wharton's jelly. In this substance are contained 
three vessels, a large vein and two small arteries. The relative 
disposition of these vessels is variable. The arteries and the vein 
may pursue a parallel course without a trace of twisting (Fig. 53). 
The vein may be twisted around the arteries (Fig. 54) in a spiral 
form. The two arteries may twist around the vein (Fig. 55). 
Finally, the twisting of the three vessels may be simultaneous and 
reciprocal (Fig. 56), 



Furicubr artery. 




Funicular vein. 
Wharton's jelly. 
Amnion. 

Fig. 52. — Transverse section of the cord. 



As anomalies, I may note the absence of one artery, or the 
presence of a third. Exceptionally, there may be two or three veins. 



Fio. 53. 



Fig. 54, 



Fig. 55. 



Fig. 56. 



In the interior of the vessels are found incomplete semilunar 
valves, which sometimes become circular, like a diaphragm. The 
physiological role of these valves is not well known, and besides, 
must be of slight importance, since the obstruction they produce is 
incomplete. They may play a certain part in the production of the 



56 Development and Description of the Human Ovum. 

funicular souffle. The existence of fine vessels in the cord, the vasa 
projma (Euge), has heen noted ; the existence of lymphatics and 
nerves has not been proven. 

Physiology. — The cord serves to unite the mother and the foetus, 
through the intermediate placenta. The blood carried to the pla- 
centa by the umbilical arteries is returned to the foetus by the 
umbilical vein, after having undergone respiratory and nutritive 
modifications in the placenta. Contrary to the usual purposes of 
these vessels, it will be observed that here the arteries carry the 
dark blood and the vein the red blood. 

III. Embryonic portion of the ovum, — The foetus at term. 
— There is no positive sign that Avill permit us to affirm that the 
foetus is at term ; thus we are obliged, for this determination, to use 
a series of points which, as a whole, afford some certainty. The 
points are : 

1. The information furnished by the mother, on the subject of 
the probable duration of the pregnancy, at the moment of delivery 
(last menstruation,. a single coitus, first movements of the foetus'. 

2. The weight of the child, which is, on the average, three kilo- 
grammes, attaining quite often three thousand five hundred grammes, 
but the variations from greater to less may be considerable — max- 
imum nine thousand grammes (Eiembault) ; minimum, one 
thousand three hundred grammes (Blot) . It must a] so be understood 
that this inferior limit is somewhat arbitrary, in the default of exact 
knowledge of the date of conception. 

3. The length of the foetus, measured from head to foot, is 
generally fifty centimetres — equal to that of the umbilical cord. 
Variations of five centimetres, more or less, are not rare. 

4. The development of the nails and hair is too variable to be 
taken into serious consideration. In general, in the foetus at term, 
the nails exceed the extremity of the finger. The hair presents a 
length of two to three centimetres, or even more, and the fine down 
which covers all the hairy regions appears more developed before 
term than at term . 

5. In the male infant the testicles have descended into the 
scrotum, but this descent sometimes occurs before term, and does 
not always exist at term. 

6. The ossification of the skull, the only bones that can easily be 
explored in the living child, is too variable in its degree to afford 
clear information. In the dead foetus there may be recognized in 
a section of the inferior part of the femur a point of ossification 
that Beclard considers a positive sign of the maturity of the foetus. 
The researches of Hecker and of Hartman have shown, however, 
that it sometimes exists before term, and that it may be wanting 



Development and Description of the Human Ovum. 



57 



at term. No one of these signs is positive, then, but their recog- 
nition permits an approximate valuation, generally sufficient to 
determine if the child is at full term. 

Form and topography. — The general form of the foetus, rolled 
up in the cavity of the uterus, is ovoid (Fig. 58), the large extremity 
corresponding to the breech and the small to the head. This is the 
somatic ovoid. 





Fig. 57. — Beclard's point cf ossification. 



Fig. 58. — Somatic ovoid. 



The somatic ovoid may be divided into two secondary ovoids : 
Cephalic (head), cormic (trunk). These are united by the neck. 

The topography of the cormic ovoid needs no special consider- 
ation; the foetal trunk is identical, with smaller dimensions, with 
that of the adult; it is an adult in miniature. 

This is not true with regard to the cephalic ovoid. In exploring 
the head of the new-born, the union of the bones which compose it 
is found. These are real solutions of continuity (sutures and fonta- 
nelles) that are of considerable importance in obstetrics, for a 
knowledge of them permits diagnostication of the situation and the 
relations of the cephalic extremity which presents during delivery. 

The sutures are the lines of union of two contiguous bones and 
the fontanelles are the confluents formed by the meeting of two or 
more sutures. 

I^Ylq fontanelles are two, principal or median; and two, secondary 
or lateral. 

The two median fontanelles are : 

1. The lambda, or the posterior fontanelle (small fontanelle), at the 
union of the occipital and the two parietal bones, a virtual fonta- 
nelle, for the bones do not leave a free space at this point. 

2. The bregma, or anterior fontanelle (great fontanelle), at the 
union of the parietal and the frontal bones, a real fontanelle, con- 
stituted by a large fibrous space, having the form of a lozenge, the 



58 



Development and Description of the Human Ovum, 



frontal borders being more prolonged than the parietal. This fonta- 
nelle generally closes two or three months after birth. 
The two se.condary, or lateral, are : 

1. Asterion, at the union of the occipital, the parietal and the 
temporal bones, a virtual fontanelle. 

2. The pterion, at the union of the frontal, the parietal and the 
temporal bones and the great wing of the spenoid, likewise a virtual 
fontanelle and only of slight importance. 




Fig. 59. — View of the upper part of the head. 

Finally, there exist, as anomalies and consequently as accessory, 
two other median fontanelles : 

1. The obelion, a lozenge- shaped space, at one or two centimetres 
in advance of the lambda on the biparietal suture. 

2. The glabella, a fibrous median space, of oval form, sometimes 
found on the bifrontal suture at about two centimetres from the 
root of the nose. 




!3«0>! 



Fig. 60. — Lateral view of the head. 

The sutures are named from the bones which enter into their for- 
mation. These we find : 

1. The biparietal suture, wiiich, beginning at the occiput, is 



Development and Description of the Hunan Ovum. 59 

continuous, after traversing the bregma, with the bifrontal suture. 
These two sutures together are designated as the sagittal suture. 

2. The occipito-parietal suture, also called the lamdoid, on 
account of its analogy with the Greek letter of the same name. 

3. The fronto-parietal suture, wliich cuts the sagittal perpendicu- 
larly and terminates laterally in the pterion. 

4. The temporo-parietal suture unites the squamous portion of 
the temporal to the parietal. 




C C. I PUT 

Fig. 6i. — Cephalic planisphere. 



^'Q 



The other sutures present only a secondary importance and do 
not merit especial mention. In the track of these sutures, in par- 
ticular the biparietal suture toward its posterior portion, there exist 
some separate bones, more or less disfiguring the topography and 
interfering with the diagnosis. 



60 Development and Description of the Human Ovum. 

Diameters. — If the two foetal ovoids were regular, it would be suf- 
ficient to take the length and the width to recognize the exact 
dimensions, but their irregularities necessitate the determination of 
a certain number of diameters, with which the physician should be 
familiar if he wishes to comprehend the mechanism and the diffi- 
culties of delivery. Let us study successively the two ovoids, the 
cephalic and the cormic. 

A. The cephalic ovoid. — The foetal head is composed of two parts 
that are essentially different : One forms an irregular plane, a solid 
osseous mass, extending from the occiput to the face, this is the 
base of the cranium. The other constitutes a case enclosing the 
brain and surmounting the base, with which it is continuous by its 
base, this is the vault of the cranium. The vault is of predominant 
importance in normal delivery and in dystocia, when perforation 
and crushing are not necessary but when the cerebral substance 
must be evacuated to reduce the head ; the base, on the contrary, 
opposes the obstacle to delivery. Thus is seen the different roles 
of these two portions of the head and the necessity of measuring 
their principal diameters. 

The vault of the cranium, that is, the intact head, has three 
principal diameters : 

1. The mento-maximtim, extending from the point of the chin to 
the most distant point of the sagittal suture', at some millimetres in 
front of the lambda. 

2. The biparietal, joining the two parietal protuberances. 

3. The bitemporal, extending from one pterion to the other. 

The base of the cranium has also three principal diameters : 

1. The inio-nasal, which extends from the inion to the root of the 
nose. 

2. The bimalar, uniting the two malar tuberosities. 

3. The biosteric, extending from the asterion to that of the oppo- 
site side. 

Aside from these diameters, which are to a certain extent static, 
there are others, of an importance only comprehended after the 
study of the mechanism of delivery, which may be called dynamic. 
I will only simply mention them here, returning later to their study 
apropos of parturition. These are : 

1. The suboccipito-bregmatic, extending from the union of the 
occiput and the neck to the center of the bregma. 

2. The suboccipito-maximum, from the same posterior point to 
the most distant part of the bifrontal suture. 

3. The submento-bregmatic, from the union of the chin and the 
neck to the center of the bregma. 

4. Submento-maximum, from the same anterior jjoint to the 
most distant part of the sagittal suture. 



Development and Description of the Human Ovum. 61 

The dimensions of these different diameters are as follows : 
Static diameters. — 

Mento-maximum, I3j^ centimetres. 
Inionasal, 11)4 centimetres. 
Biparietal, g)4 centimetres. 
Bitemporal, S)4 centimetres. 
Biasteric, 7^ centimetres. 
Bimalar, 6^ centimetres. 

Dynamic diameters, — 



Suboccipito-bregmatic, 9^ centimetres. 
Suboccipito-maximum, loj^ centimetres. 
Submento-bregmatic, 9^ centimetres. 
Submento-maximum 1 1 centimetres. 



For the last, lOJ could be admitted, but it is important to know 
that it is greater than the suboccipito-maximum, and we would 
then have a series of figures easily retained, 6 J, TJ, SJ, 9], lOJ, 11 J-, 
13 J, from 6 to 13, with the exception of 12, by adding a half to each. 

The mento-maximum and the inio-nasal, as well as the dynamic 
diameters, are antero-posterior, the others are transverse. 

B. The cormic ovoid. — The trunk of the foetus, much more irregular 
and more reducible than the head, also presents several diameters, 
which are, on account of its compressibility, only of secondary 
importance. I will only note : 

1. The bitrochanteric, uniting the two trochanters. 

2. The pubo-sacral, .extending from the upper part of the sacral 
promoting to the middle of the anterior surface of the p'ubes. 

3. The bisacromial, from the acromion of one side to that of the 
opposite side. 

4. The sterno- dorsal, a horizontal line from the middle of the 
sternum to the corresponding spinous apophysis. 

The diameters measure on the average : 

Pubo-sacral, 6 centimetres. 
Bitrochanteric, 9 centimetres. 
Sterno-dorsal, 9 centimetres. 
Bisacromial, 12 centimetres. 

Figures 6, 9, 12 are easily retained. 

According to these dimensions one would be led to believe that 
the thorax forms the large extremity of the cormic ovoid and the 
breech the smaller portion, but the two diameters of the breech are 
much less reducible than those of the thorax and the addition to the 
pelvis of the lower limbs folded on themselves considerably increases 
the volume of this foetal part and renders it really larger than the 
thoracic. 

Physiology. — A. Circidation. — The foetus presents two distinct 
circulations during its sojourn in the uterine cavity. The first 
(embryonic), depending on the umbilical vesicle ; the second (foetal), 
developing with the allantoid vesicle and replacing the preceding, 
this is the placental circulation. 



62 



Development and Description of the Human Ovum. 



The fcBtal circulation (Fig. 62) differs from the definitive in two 
essential points: 1. By the existence of a funicular placental 
territory, which brings the foetal blood in contact with the maternal. 



4 r^^ 




Piacenla 
Fig. 62. — Schema of the foetal circulation. 



2. By the communication of the aortic with pulmonary circulation 
in two ways : «., through the foramen ovale (Fig. 62 B), which con- 
nects the two auricles ; 6, the ductus arteriosus, uniting the pul- 
monary artery and the aorta. These communications, which are 



Development and Description of the Human Ovum. 63 

destined to disappear at birth, permit the blood to laake the com- 
plete round of the circulation without passing through the lungs, 
and these structures remain rudimentary curing intrauterine life. 

B. liespiration. — This function comprises three successive ^yo- 
cesses : 1. The oxygenation of the blood, accompanied by the 
elimination of carbonic acid. 2. The transportation of oxygen to 
the different tissues of the organism by the intermediatory circu- 
lation. 3. The deoxygenation of the blood, with combustion as its 
result. The last two processes are only present in the fcetus to a 
small degree. The first process is essentially different from that 
of the adult by occurring in the placenta instead of in the lung. In 
passing through the placenta the foetal blood absorbs oxygen from 
the maternal circulation and discharges its carbonic acid. Every 
cause of arrest of the placental circulation, of partial or total sup- 
pression of the function of the placenta, leads to asphyxia of the 
foetus. 

C. Nutrition. — The nutrition of the foetus is carried on both by 
the blood and liquor amnii. In the placenta the blood is charged 
with the nutritive elements contained in the maternal circulation, 
for the placenta permits the filtration of solid, liquid and gaseous 
elements. The nutritive role of the amniotic liquid is not so well 
established as that of the blood. It possesses nutritive qualities 
for it contains albumin and salts. It is swallowed by the foetus, 
for experiments on animals by freezing have shown the existence 
of ice extending from the amniotic liquid through the mouth and 
oesophagus to the stomach. Examination of the meconium under 
the microscope has also shown the existence of numerous hairs from 
the skin, which could only be drawn in with the liquor amnii. But 
nutrition exists in monstrosities in which the mouth is absent and 
also in the early months of intrauterine life when deglutition is im- 
possible, so that if the liquor amnii fulfills any nutritive purpose 
at all it is very slight compared with that of the placenta. 

D. Secretions. — The skin furnishes the vernix caseosa which at the 
moment of birth covers the foetus like an irregular false membrane. 

The intestine secretes the meconium, a mixture of bile, cellular 
debris and different elements found in the liquor amnii. Except 
under special conditions, the meconium is only expelled after birth. 

The kidneys also act during pregnancy. The urine accumulates 
in the bladder, and then passes into the liquor amnii. Obliteration 
of one of the ureters produces hydronephrosis, and that of the 
urethra, retention of urine with distention of the bladder — a proof 
of the existence of micturition during intra -uterine life. 

E. Innervation and motility. — Sensibility and motility exist in the 
foetus, every excitation conveyed to it is interpreted by movements. 
Iti3 also probable that during intra-uterine life there are alternatives 
of sleeping and waking. 



64 Modifications of the Maternal Organism, 



CHAPTER III. 



MODIFICATIONS OF THE MATERNAL 
ORGANISM. 

We have studied the ovum during its development in the uterine 
cavity, it is now important to study the parallel modifications wliich 
occur in the maternal organism. These modifications are not 
localized, as might be supposed, in the genital system, but involve 
the whole economy. It will then be necessary to successively examine 
all the systems. I shall begin with the genital apparatus as the one 
most directly interested. 

I. Genital system and vicinity. — Some special anatomical consider- 
ations are necessary to a proper understanding of this subject. 

The uterus is the organ in which the ovum is developed during 
normal pregnancy. Situated in the pelvic cavity, with the rectum 
behind and the bladder in front, it unites the vagina to the tubes. 

The general form of the uterus is that of a pear, the large ex- 
tremity constituting the body, the small the cervix. The body and 
the cervix are united by a thinner part, the isthmus. In the 
normal state the axis of the uterus is rectilinear, that is, the body 
and the cervix have the same direction. This uterine axis is nearly 
identical with that of the superior strait and is perpendicular to 
that of the vagina. However, the axis of the uterus is perpendicular 
to that of the vagina only when there is a certain degree of repletion 
of the bladder. But, after the evacuation of the urine, ante-devi- 
ation occurs. Thus the uterus lies on a cushion of water and fol- 
lows its variations. The uterus is held in its normal position by 
by the support given to it by the pelvic floor. 

The longitudinal dimension of the uterus is six centimetres and 
a half, which is divided as follows : 

Cervix, ..... 0,025 

Isthmus, ... - - 0,005 

Body, cavity, .... 0,025 

Thickness of the wall, - - 0,010 



0,065 

These dimensions represent the average as apphed to all uteri. 
It should not be forgotten, however, that in the nulliparous woman 
the cavity of the cervix is greater, and in the multiparous that of 
the body. 

Weight : forty grammes. 

The uterus is covered by the peritongeum in the greatest part of 
its extent except over the three regions shown in Fig. 65. This 



Modifications of the Maternal Organism, 



65 



membrane separates it from the bladder in front, from the in- 
testines above and from the rectum behind. The fundus of the 
uterus is situated about three centimetres above the horizontal plane 
passing through the superior portion of the symphysis pubis. 

I have already described the interior of the uterus under head of 
menstruation and it is sufficient to say here that the external orifice 
is rounded and sometimes punctiform in the nulliparous woman, 
that it is transversely elongated after a first parturition, and that, 
in consequence of multiple lacerations, it may have a stellate or an 
irregular appearance. 




Uterine mucosa. 
Cavity of the body. 

Isthmus. 

Arbor vitae. 

Branches of arbor vitse. 

Vaginal cul-de-sac. 
Vagina. 
Fig. 63. — Vertical and transverse section of the uterus. 

The uterus is composed of an important muscular coat, ineom= 
pletely covered by a serous membrane, and lined on its interior by 
a mucous covering that we have akeady studied. The muscular 
tunic is exclusively composed of non-striated fibres. It differs in 
the body, in the isthmus and in the cer\dx. 

Body. — Fig. 67 schematically represents this structure. In the 
center, forming the framework, is a plexiform layer formed by inter- 
lacing muscular fibres with the meshes occupied by the arteries and 
the veins which dilate during pregnancy to form veritable sinuses. 
Above this plexiform layer is the superficial muscular layer com- 
prising an antero-posterior loop, which, commencing at the isthmus 
in front, follows the median line of the uterus to terminate behind 
at a corresponding point. Then there comes a series of transverse 
fibres, which are prolonged in part into the broad ligaments. Be- 
neath is the deep muscular layer, also comprising two arrangements 



66 



Modifications of the Maternal Organism. 




Fig. 64. — Antero-posterior and median section of the female pelvis. 





Fig. 65. — Profile view of the uterus. 



Fig. 66.— Relations of the cervix 
(Schroeder). 



Modifications of the Maternal Organism, 



67 



of fibres ; one transverse, forming a series of irregular rings, the 
others in the form of a Z. This series of fibres in the form of a Z 
are directly in contact with the mucosa. 



Deep layer, transverse fibres. 
Fibers in Z, vertical part. 

Fibers in Z, inclined part. 



Superficial layer, vertical fibres. 
Superficial layer, transverse fibres. 
Plexiform or middle layer. 




Fig. 67. — Transverse section of the uterus, at the level of the body (schema). 

Isthmus. — In the isthmus we only find transverse or slightly 
oblique fibres, that is, the plexiform layer does not reach here, but 
only the superficial loop fibres and those in the form of a Z. 

Cervix. — The same is true of the cervix, but there is, however, 
difference between the isthmus and the cervix, as in the latter the 
connective tissue element predominates while in the isthmus the 
muscular fibres are more abundant. 

These anatomical considerations permit us to pass to the study 
of the modifications of the uterus under the influence of pregnancy. 
These modifications are of three kinds : 

A. Macroscopic. 

B. Microscopic. 

C. Physiological. 

A. Macroscopic modifications. — The body containing the ovum 
and the cervix opposing its egress, assume a physiological role 
essentially different. The modifications of these two parts of the 



68 



Modifications of the Maternal Organism, 



uterus are completely dissimilar, from which arises the necessity 
of studying them separately. 

1. Modifications of the hody.— Volume,— 1 shall only speak of the 
vertical diameter, which measures fourteen centimetres at the 
third month (not including the cervix) ; twenty-one in the sixth 
month, and thirty-five in the ninth month. 



Fig. 68. 

Uterus empty 
(profile view). 



Fig. 69. 

First three months 

of pregnancy 

(uterus rounded). 



Fig. 70. 

Second 

three months of 

pregnancy. 



Fig. 71. 

Third three months 
of pregnancy. 




Fig. 72. 

First three months. 

Uterus in pelvis 

(front view). 



Fig. 73. 

Second 

three months. 

Uterus in abdomen. 



Fig. 74. 

Third three months. 

Abdominal-pelvic 

situation. 



Capacity. — The capacity of two to three cubic centimetres in an 
empty state is increased to four or five litres. 

Form. — The uterus becomes rounded during the first three months 
ot pregnancy, while increasing in volume. During the second three 
months, the uterus especially increases in its postero- superior part, 
in the region indicated in Fig. 70, by a series of small projections, 
in such a manner that the openings of the tubes are carried below 
and a little forward. During the last three months it is especially 
the antero-inferior part which develops, in such a way that the 
cervix is thrown backward. The general form of the uterus at 
term is, as before pregnancy, that of an ovoid with the small ex- 
tremity downward. 



Modifications of the Maternal Organism, 69 

Situation, — During the first three months of gestation the uterus 
is developed in the interior of the pehic excavation. The fundus 
passes the superior strait and encroaches on the abdominal cavity 
(-Fig. 71). 

In the second three months the uterus, becoming too large for 
the pelvic cavity, ascends into the abdominal cavity above the 
superior straight (Fig. 73). 



Umbilicus, middle of 
pregnancy. 



Fig. 75. — Gradual elevation of the uterus in the abdominal cavity. 

During the last three months the situation of the uterus varies in 
the primiparse and in the multiparee. In the primiparee, early 
descent of the uterus into the pelvic excavation, with engagement 
of the foetal part, takes place, especially during the last two months 
(Fig. 74). In the multiparse the lax abdominal wall allows 
sufficient room for the distention of the uterus, and engagement 
only occurs during the last fifteen days of j)regnancy, sometimes 
even later. 

The relation of the fundus of the uterus to the abdominal 
wall (Fig. 75) is interesting to determine, for it serves as a mark 
from which an approximate estimation of the date of the pregnancy 



70 Modifications of the Maternal Organism. 

may be made. Unfortunately, great variations exist. However, 
it may be said in a general way that : 

During the fourth month the uterus is a little below the um- 
biHcus ; during the fifth, at the level of the umbilicus ; during the 
sixth, a little above the umbilicus; during the seventh, three 
fingers' breadth above the umbilicus ; during the eighth, six fingers' 
breadth above the umbilicus, and during the ninth month, nine 
fingers' breadth above. 

Orientation. — The uterus presents three principal axes, an antero- 
posterior, a vertical, and a transverse. Now, during pregnancy, it 
may undergo various deviations by turning on these axes. 

1 Antero-posterior axis. — Lateral inclination. — I suppose this axis 
passing in the vicinity of the cervix. Movements of the uterus 
around this fictitious line incline its fundus to the right or to the 
left. From the statistics of one hundred cases I have deduced the 
following : 

Right inclination, 55 per 100. 
Left inclination, 5 per 100. 
No inclination, 40 per 100, 





Fig. 76. — Median uterus, symmetrical Fig. 77. — Apparent inclination of the 

development of the two halves of the uterus, asymmetrical development of the 
organ. of the two halves of the organ. 

Various causes have been invoked to explain this lateral incli- 
nation of the uterus ; among them are : Decubitus, preponderant 
usage of the right or of the left arm, the situation of the placenta, 
the relative length of the round ligaments, the anatomical dispo- 
sition of the mesentary, and vesical or rectal repletion. But none 
of these explanations are satisfactory, and it seems the mode of 
development of the uterus, either symmetrical or asymmetrical, 
affords a better account of these lateral deviations. The sym- 
metrical development of the two halves of the organ gives a uterus 
which appears median (Fig. 76), while asymmetrical development 
imposes a right (Fig. 77) or a left inclination. Thus the inclination 
of the uterus is apparent and not real. If real inclination occur, 
it is consecutive to the preceding. 



Modijications of the Maternal Organism, 



71 



2. Vertical axis. — Eotation is the movement round the vertical 
axis. The anterior surface of the uterus is generally inclined to- 
ward the side where the organ is most developed. This rotation is 
important with regard to a Caesarian operation, for if the direction 
is not corrected there is danger of wounding some important vessels. 





Fig. 78. — Normal gravid abdomen. Fig. 79. — Pendukms gravid abdomen. 

3. Transverse axis. — Antero-posterior inclination. — I suppose this 
axis passing through the union of the body and cervix. During 
the first three months, rarely later, the body of the uterus may in- 
cline backward, thus constituting retroversion of the gravid uterus, 
which we shall study further on. During the latter part of preg- 
nancy this posterior deviation is impossible, on account of the size 
of the uterus, but anteversion may occur with a very lax abdominal 
wall (Fig. 79). 

Weight. — Thickness. — The weight of the uterus attains about a 
kilogramme at term (not including the fcetus). The thickness of 
the uterus is, normally, five millimetres. Opinions on this subject 
differ greatly. Some authorities say it is thinner, some that it is 
thicker, and some that it remains the same during pregnancy, 
and all have autopsies to bear them out. These different obser- 
vations demonstrate the inconsistency of its thickness. There exists 
in general a notable difference between the superior segment and 
the inferior, the latter being relatively very thin. Points of the 
uterus which have supported a prolonged compression, like that of 
the foetal head, are diminished in thickness. The surface of the 
insertion of the placenta is hypertrophied, on the contrary. 

2. Modifications of the cervix. — The cervix is modified in its form, 
in its situation, in its volume and in its consistence. The efface- 
ment, that is, the disappearance of the cervix which precedes the 



72 



Modifications of the Maternal Organism. 



opening of the external orifice, although sometimes occurring during 
pregnancy, will be studied with accouchement. 



Fig. 8o. 



Fig. 8i. 




Fig. 82. 



Fig. Ss. 




a, uterine circle (Bandl's ring) limit between the supero-lateral and inferior 
segments; b, internal orifice; c, external orifice. 

Form. — Outside the modifications of form caused by effacement 
there may be found, aside from the normal type often persisting in 
the primiparse, one of the three principal forms represented in the 
adjoined schema (Figs. 80, 81, 82 and 83). These modifications 
are due to the degree of the relative dilatation of the two orifices of 
the uterus. 

Situation, — The cervix naturally follows the body in its evolutions. 
During the first three months the cervix is found in its natural 
position, often a little approached to the perinaeum. During the 
second three months the cervix follows the uterus in its ascent and 
becomes less accessible to vaginal touch. During the last three 
months its situation differs in the primipara from that in the multi- 
para. In consequence of the progressive engagement during the 



Modifications of the Maternal Organism, 



73 



last three months m the primipara, the cervix descends and is also 
usually deviated to the left and a httle backward. Earely the cervix 
is median or to the right. In the multiparse, engagement takes 
place later, and the situation of the cervix varies with degree of the 
uterine descent. With regard to cervical deviations, they are the 
same as in the primiparse. 





Figs. 84 and 85. — Folds of the vagina during pregnancy. 




Fig. 86. — Ligaments of the uterus seen from above. 

Volume. — Hypertrophy of the cervix is generally admitted, under 
the influence of pregnancy, in such a manner that its length is 
doubled ; from twenty-five millimetres it is increased to five centi- 
metres. We shall return to this apropos of effacement. 



74 Modifications of the Maternal Organism. 

Consistence. — The cervix progressively diminishes in consistence 
during pregnancy. This softening does not occur as a whole, but 
from the external orifice toward the internal, following progressive 
invasion like that of an epithelioma. This softening is sometimes 
so great that the examining finger can scarcely perceive the cervix 
in the midst of the vaginal tissues. Attempts have been made to 
base a diagnosis of the date of pregnancy on the extent of the soften- 
ing of the cervix, but, even in a first pregnancy, the variations are 
too great to allow us to accord this sign any such degree of precision. 
This modification is probably due to a serous infiltration and to 
microscopic changes occurring in the cervix. It is to be noted that 
all the tissues of the genital zone, and in particular those of the 
vulva, undergo an analogous softening, though less in degree, and 
equally accompanied by hypertrophy, 

B. Microscopic modifications. — In studying the development of the 
ovum we have seen the modifications of the uterine mucosa which con- 
stitute the decidua. Only the mucous membrane of the body and of the 
isthmus undergo this transformation. In the cervix the mucosa, out- 
side of functional superactivity and epithelial proliferation, does not 
present any change. The cervical glands secrete a viscous liquid 
of such great consistence that it forms a veritable obdurator, a 
gelatinous plug which is cast out at the beginning of labor. The mus- 
cular fibres undergo modifications of hypertrophy and multipli- 
cation both in the body and in the cervix cf the uterus, but less in 
degree in the latter. 

The peritonaeum is hypertrophied and enlarged to accommodate 
the increase in the surface of the uterus. The afferent arteries of 
the uterus take on considerable development, sufficient to assure a 
complete supply of blood to the organ. The veins undergo a parallel 
development, forming true sinuses in the muscular wall. There 
is an analogous increase in the size of the lymphatics. The nerves 
also appear hypertrophied. 

C. Physiological modifications. — The uterus is essentially a mus- 
cular organ and like all the other viscera it is connected with the 
central nervous system by the centrifugal and the centripetal nerves. 
The presence of nerves creates two properties, sensibility and irri- 
tability. As a muscular organ the uterus possesses extensibility, 
retractility and contractility. These five physiological properties 
are more or less modified by the puerperal state : 

1. The sensibility of the uterus, body and cervix, is obscure. In 
the normal state the uterine surface can be attacked without causing 
acute pain. On the contrary, in the pathological state this suscepti- 
bility is capable of arising quickly. Under the influence of uterine 
contraction during labor the pain becomes severe, as much in the 
cer\dx as in the body. This difference in the results produced by 



Modifications of the Maternal Organism. 75 

contact and by contraction justifies the special nature attributed to 
uterine sensibility. 

2. The uterus is irritable, that is to say that an excitation arising 
in any sensitive zone is transmitted to the uterus reflexly and causes 
a contraction. The majority of the methods employed to cause 
abortion act by bringing this property of the uterus into play. 

3. Extensibility permits the uterus to distend progressively with 
the development of the product of conception. Without it pregnancy 
would be impossible. During gestation the body of the uterus 
undergoes extension; at the moment of labor the cervix and the 
inferior segment are extended in turn. 

4. Eetractility is opposed to extensibility. By this property the 
uterus has a tendency to diminish in volume, like a rubber balloon. 
Eetractility is only the efl'ect of the tonicity possessed by the uterus 
in common with all other muscles. Pathological exaggeration of 
retractility produces uterine tetanus and its absence creates uterine 
inertia. 

5. Contractility is constituted by the momentary contraction of 
the uterus as a whole. It results in a diminution of the capacity 
of the organ or in a tendency to this diminution. In an empty 
state of the uterus contractions are painless and are not felt except 
in pathological conditions, such as pseudo membranous dysmenor- 
rhoea. During pregnancy they are also painless, and if they are 
perceived at all it is as a passing hardness of the abdomen. On the 
contrary, contractions become painful during labor. 

II. Vagina, — Vulva, — Perinceum. — These structures undergo two 
principal modifications, hypertrophy and softening, occurring in 
common with the same changes in the uterus, thus preparing a 
favorable condition for the exit of the child. 

A. Vagina. — The vagina increases in all its dimensions. Its 
elongation facilitates, in the second tliree months of pregnancy, 
the ascension of the uterus. When, during the last three months, 
the uterus descends again the vagina, is folded on itself (Figs. 84 
and 49). The vascular system undergoes an equal development, 
having the double effect of modifying the coloration of the vagina 
and of making the arterial pulsations perceptible in some cases 
(vaginal pulse of Osiander). 

B. Vulva. — Besides hypertrophy and a certain degree of softening 
the vulva undergoes two other important modifications. A pigmen- 
tation analogous to that of the breast or of the face and a violaceous 
coloration, more marked on as the vagina is approached. 

C. Perinceum. — The perinseum, participating in the softening and 
in the hypertrophy of the tissues of the genital zone, acquires under 



76 



Modifications of the Maternal Organism. 



the influence of pregnancy a great suppleness permitting stretching 
at the moment of accouchement. Like the vulva, it often becomes 
the seat of pigmentation, especially in brunettes. 




Fig. 87. — Ligaments of the uterus, profile view. A, insertion of the broad 
ligaments; B, utero-sacral ligament; C, utero-vesical ligament. 

III. Aiypenclages of the uterus. — I shall study the modifications of 
the ligaments \Yith the enclosed vessels, by describing the modifi- 
cations impressed on them by pregnancy. 

A. Ligaments. — During pregnancy all the ligaments undergo a 
notable hypertrophy with a certain degree of softening, as in all the 
organs of the genital zone. The suppleness acquired by the utero- 
sacral ligaments permit the ascension of the cervix during the second 
three months of pregnancy. With regard to the broad ligaments, 
the contraction of their muscular fibres play, according to the 
demonstrations of Thevenot and Budin, an important role in the 
engagement of the uterus and of the foetal part. Their contraction, 
synergetic with the pressure exercised by the abdominal wall, causes 
the foetus to descend into the excavation ; their relaxation permits 
the ascension of the uterus. 

The tube and the ovary, contained in the broad ligament, par- 
ticipate in the general hypertrophy of the genital system. The 
ovary in particular, which has furnished the fecundated vesicle, 
sometimes acquires the volume of a small walnut. Budin has 
justly insisted on the pain which is often caused by palpation of 
the ovaries during pregnancy. 

B. Bloodvessels. — The adjoined plate brings these structures to 



Modifications of the Maternal Organism. 



77 



memory sufficiently without necessitating further description. All 
these vessels, especially the veins, assume a considerable develop- 
ment during gestation. 



VEINS. 



ARTERIES. 




UEP 



Fig. 88. — Bloodvessels of the genital system. A A, ac^rta; R, renal artery ; A U O, 
utero-ovarian artery; AIG, left primary iliac artery; A P, puerperal artery; AU, 
uterine artery; All, internal iliac artery; A IE, external iliac artery; A EP, epi- 
gastric arteries; A LR, artery of the round ligament; A V, vaginal artery; OV, 
ovary; TR, tube; V, vagina; UT, uterus. Veins: corresponding deviations on the 
opposite side. 

C. Lymphatics. — The role of the lymphatics is small in the physi- 
ological state, but is more important in cases of puerperal septi- 
caemia. The uterine lymphatics pass to a series of glands grouped 
in the pelvis, as indicated in Figure 89. 

lY. Articulations of the pelvis. — The three articulations which es- 
pecially fix the attention are the two sacro-iliac symphyses and the 
symphysis pubis. As a whole, they may be considered as three 
breaks in the pelvic ring which give it greater flexibility. This 



78 Modifications of the Maternal Organism. 

appears to be their special use. Under the influence of pregnancy 
the peripheral ligaments of these articulation relax, and the intra- 
articular ligaments undergo a certain degree of softening with 
hypertrophy. These modifications cause a slight separation of the 
articular surfaces. 



_ ~ Guerin's retro-pubic 
glands. 



Satellite glands of the 
uterus. 

Uterus. 



Lateral pelvic glands. 
Sacral glands. 
Fig, 89. — Lymphatic glands of the pelvis. 

V. Abdominal IV all. — The umbilicus seems deeper during the first 
three months of pregnancy, as if the urachus exercised traction at 
this point. Beginning with the second three months the umbilicus 
is progressively flattened and often becomes projecting in the last 
three months. These tliree periods of the changes in the umbilicus 
have only a theoretical interest. 





Fig. 90 — Lineas albicantes of pregnancy. 

The abdominal integument, distended by the enlarging uterus, 
presents a series of subepidermic cracks, forming small plaques of 
cicatricial appearance. These are the linese albicantes of preg- 
nancy. These vibices particularly occur in the subumbilical 



Modifications of the Maternal Organism. 79 

region and parallel to the fold of the groin. They may also invade 
the whole extent of the abdomen, £on:etimes even the buttocks and 
npper part of the thighs. By anomaly, Ihey are exclnsiyely situated 
in one of these two regions. They are rosy or bluish when recent; 
in multiparse those dating from a previous pregnancy have a pearly 
reflex. They diminish in extent after pregnancy, but never dis- 
appear entirely. In five cases out of one hundred they are wanting. 
These subcutaneous ruptures are not exclusively observed during 
pregnancy; they may be produced by any cause of abdominal 
distention. 




Fig. 91. — Nipple. True and secondary areolae. Tubercles of Montgomery. 

6. Breasts, — We will only touch here upon the question of the 
superficial changes of the nijDple, the areola, and of the contiguous 
integument. The nipi)le increases in size, becoming erectile and 
sensitive, even hyperaesthetic and painful. Around the nipple there 
are two zones of unequal coloration, the most eccentric being the 
least deeply colored. The first is the true areola, existing before 
pregnancy and becoming more pign^ented under its influence. The 
hypertrophy of Mongomery's tubercles and the pigmentation are 
the two principal characters of the areola during gestation. The 
other, the secondary areola, is a pigmentation of gravid origin, 
and forms a circle surrounding the first. The subcutaneous venous 
plexus becomes very apparent. By compressing the nipple toward 
the end of pregnancy some drops of colostrum often exude. The 
colostrum sometimes flows spontaneously. 

II. Nervous system. — A. Central. — The sensitiveness of the preg- 
nant woman is usually exaggerated. The intelligence is also 
affected, so that a naturally vivacious woman becomes dull when 
pregnant. Exceptionally, a contrary modification has been noted. 
Various perversions in the form of morbid desires are to be noted. 
Alterations of the will are also often present and border on insanity 
in some cases. 



80 Modifications of the Maternal Organism. 

B. Peripheral. — Pregnancy predisposes to diverse neuralgias, and 
in particular to odontalgia, especially in women whose dental 
system presents a previous physiological inferiority. 

III. Respiratory system. — The development of the uterus causes 
an increase in the transverse diameter of the thorax, and on the 
contrary a diminution of the antero-posterior and of the vertical. 
The general capacity of the thorax is diminished, producing a 
certain obstruction to respiration, that is increased by the globular 
poverty of the blood, another effect of pregnancy that we shall soon 
explain. This double cause exposes the pregnant woman to breath- 
lessness. 

IV. Circulatory system. — Blood.— There are three principal modi- 
fications of the blood, namely, serous plethora, globular anaemia 
(except as to the leucocytes), and diminution of the solid principles 
(except fibrin). The quantity of water composing the blood is 
notably increased, so that the total mass of the sanguineous liquid 
is greater during pregnancy. There is then a plethora, but a 
serous plethora or hydrgemia. From the exaggeration of the vas- 
cular tension there arises in the capillaries a quantity of serum, 
causing a generalized swelling of the tissues. This swelling should 
not be confounded with a certain degree of adipose tissue which is 
a frequent result of pregnancy as we shall see later. 

Besides the general infiltration of the tissues the augmentation 
of the total amount of blood has two other effects : predisposition 
to haemorrhages and obstruction of the functions of certain organs, 
in particular, of the heart (hypertrophy, dilatation) and of the 
kidney (congestion, nephritis, albuminuria). The greater vascular 
tension produces more energetic pulsation on the part of the 
arteries and a tendency to dilatation on the part of the veins, 
frequently terminating in the production of varices. 

V. Urinary system. — In the kidney we find congestion and ob- 
struction due to the general modifications of the circulation and to 
the compression exercised by the voluminous uterus. From this 
arises a predisposition to nephritis and disturbances of secretion, 
which will be studied with the urine. 

Compression of the ureter is possible, especially when the en- 
gagement is deep, leading to arrest of the flow of urine and the 
production of eclampsia. 

In its development the uterus obstructs the bladder more or less 
by its expansion, and causes changes in the form and in the situ- 
ation of the urinary reservoir. During the first three months of 
pregnancy the conditions are not notably changed. During the 
second three months, the bladder is considerably relieved from 



Modifications of the Maternal Organism. 81 

pressure by the ascent of the uterus. During the third three 
months, and also during labor following the degree of the fceto- 
uterine engagement, the bladder takes different forms (Figs. 92, 
93, 94). The urethra follows, in part, the changes of the bladder. 



Fig. Q2 — Bladder in the form of a crescent. Ve, bladder; U, uterus ; 
R, rectum ; V a, vagina. 

The urine undergoes three principal modifications, an augmen- 
tation in the quantity of water, diminution of the solid elements 
(except the chlorides), and appearance of new elements (kiestine, 
albumin, glycose). The augmentation of the liquid portion is only 
relative, for the total quantity of urine is nearly the same during 
the pregnant state as in the normal condition. The diminution of the 
solid elements comprises the phosphates, sulphates, urea, uric acid, 
creatine and creatinine. The chlorides alone are increased. Under 
the term kiestine has been designated a special substance which 
appears on the surface of the urine of pregnant women. The presence 
of albumen is relatively rare ; I shall return to tliis subject under 
albuminuria. Apropos of glycosuria, authorities are not in accord. 
I reserve this subject for the chapter on diabetes. 

VI. Cutaneous and osseous systenns. — Besides the different situa- 
tions already noted, gravid pigmentation may occur in various other 
parts, notably on the face. The nutrition of the nails may be 



82 Modifications of the Maternal Organism. 




Fig. 93. — Bladder in the form of a slipper. 




Fig. 94. — Bladder in the form of a horn. 



Modifications of the Maternal Organism. 83 

disturbed, causing a diminution in their thickness. The skeleton 
undergoes modifications in its general attitude and in its nutrition. 
In consequence of the development of the abdomen, the woman to 
maintain her equilibrium is obliged to throw the upper part of the 
body backward. The puerperal state also seems to excite osseous 
development, as under its influence there has been noted on the 
internal surface of the cranium, and more rarely on the internal 
surface of the pelvis, the production of osteophytes in the form of 
plaques which arise with pregnancy and disappear with it. 

VII. Digestive system and appendages. — The liver undergoes an 
augmentation in volume and a fatty degeneration especially marked 
in the centre of the hepatic lobule. With regard to the digestive 
system, it is subjected to very important modifications which react 
in a marked manner on the nutrition. Gestation is capable of 
disturbing more or less deeply each one of the four acts of nutrition. 

1. Absorption. — Sometimes the appetite is excited under the 
influence of pregnancy, digestion is more easily accomplished and 
absorption seems thus favored. But usually an opposite modifi- 
cation is seen, so that a retardation of absorption can be considered 
the rule during gestation. Other causes contribute to the retar- 
dation of absorption, such as vomiting and diarrhoea. 

2. Assimilation is generally lessened under the influence of 
pregnancy, and this exercises a most unfavorable action on scrof- 
ulosis and anaemia. Scrofula already exercises an unfavorable 
action on nutrition and pregnancy ; by exaggerating this nutritive 
disturbance pregnancy hastens the evolution of tuberculosis. Aside 
from scrofulosis, the anaemia resulting from gestation sometimes 
becomes so marked that it constitutes a grave disease. 

3. Disassimilation. — If this process is complete, only three waste 
products result, that is, urea, carbonic acid and water. But if 
disassimilation is incomplete, different products arise among which 
I shall note uric acid, lactic acid, sugar and fat. The excess of 
these products in the blood, or in the eliminative organ (urinary or 
biliary passages), produces the different diseases indicated by the 
following table : 

■n, r 1 i-- -J r Rheumatism, 

Excess of lactic acid causes < r\ . ^ ■ 

{ Osteomalacia, 

Excess of uric acid causes ^ tt • ' i 

( Urinary gravel. 

Excess of fat causes - - ^-d-i-^ t^i.- • 

( Biliary hthiasis. 

•c r f Glycasmia. 

Excess oi sugar causes - < r^T ■ -rx- i_ , 

*= ( (jlycosuria, Diabetes. 

Now, pregnancy favors the development of the different diseases 
by retarding the disassimilative stage of nutrition. 

4. Elimination occurs through the skin, the intestine (comprising 



84 The Parturient Canal, 

its tributary glands, the liver in particular), the lungs and the 
kidneys. We have seen that the analysis of the gravid urine shows 
a diminution of the solid elements (except the chlorides). Eenal 
elimination is lessened then, and it is probable that the same is 
true with regard to the pulmonary, cutaneous and intestinal elimi- 
nation. When this retardation of elimination becomes too marked, 
it terminates in a pathological state, eclampsia. 



CHAPTER IV. 



THE PARTURIENT CANAL. 

The parturient canal is a narrowed and irregular region through 
which the foetus must pass at the moment of delivery. This canal 
is constituted by an osseous region, which forms its framework, 
the bony pelvis, and is completed by the soft parts below, which as 
a whole may be called the soft pelvis or peringeum. 

I. Bony pelvis. — The pelvis is formed by the two iliac bones, 
adherent at the symphysis pubis, and reunited posteriorly by the 
intermediate sacrum with its inferior appendix, the coccyx. This 
sketch allows us to note four articulations, the symphysis pubis in 
front, the two sacro-iliac symphyses, one on each side of the sacrum, 
and finally the sacro-coccygeal articulation. The pelvic ring, in- 
terposed between the vertebral column and the lower members, 
plays an important physiological part. In its description I shall 
confine myself exclusively to the obstetrical side of the question. 

External conformation. — The exterior of the pelvis interests the 
obstetrician but little; however, as in certain vices of conforma- 
tion the measurement of some external diameters furnishes useful 
knowledge, I shall indicate four of these : 

1. The sacro-pubic, from the spinous process of the first sacral 
vertebra to the anterior and median part of the symphysis pubis, 
twenty centimetres. 

2. The bispinous, separating the two anterior superior iliac 
spines, twenty-four centimetres. 

3. The bis-iliac, uniting the two most distant points of the iliac 
crests, twenty-eight centimetres. 

4. The bitrochanteric, frc^m the great trochanter of one side to 
that of the other, thirty-two centimetres. 



The Parturient Canal. 



85 



Internal conformation, — In its interior the pelvis presents two 
absolutely distinct regions, separated by a retraction that consti- 
tutes the linea-ilio-pectinea completed beliind by the promontory, 
and to vvhich is given the term superior strait. Above this is found 
the great or false pelvis ; below it is the true pelvis. 




Fig. 95. — False pelvis covered by the soft parts. A, aorta; AIPG, left primary 
iliac artery; AI EG, left external iliac artery; M P, psoas muscle; CM A, section 
of the muscles of the abdominal vi^all; GT, great trochanter; MI, iliac muscle; M 
CL, quadratus-lumborum muscle; V CI, inferior vena cava; V I P G, left primary 
iliac vein; A S V, sacro-vertebral angle; I LS, insertion of sacro-sciatic ligaments; 
M O E, external obturator muscle ; A I P, inferior arch of the pubes. 

The false pelvis forms an incomplete funnel, constituted by the 
iliac wings laterally, and the spinal column behind. The ilio-psoas 
muscles, by filling the iliac foss?e, offer a support to the gravid 
uterus when it inclines to one side. 

But the true pelvis is essentially the obstetrical part of the pelvis. 
It is limited above by the superior strait, already defined, and 
below by the inferior strait (point of the coccyx, inferior part of 
the saco-sciatic ligaments, ischium, ischio-pubic rami, inferior part 
of the pulic symphysis). 

Between these two straits is found the pelvic excavation. At the 
inferior part of the excavation a contracted portion, the median 
strait, divides it into two unequal parts : one, superior, the great 
excavation ; one, inferior, the small excavation. 

The median strait is of considerable importance in obstetrics. 
It constitutes the limit between the bony pelvis and the muscular 
pelvis ; above it, the foetus passes through a bony canal ; below it, 
through a muscular canal. Above it lies pelvic dystocia; below it 



86 



The Parturient Canal. 



(except in obstacles furnished by the ischium and coccyx) we have 
perinaeo-vulvar dystocia. 

For complete recognition of the true pelvis it is necessary to de- 
scribe successively: 

a. The superior strait. 

b. The great excavation. 

c. The median strait. 

d. The lesser excavation. 

e. The inferior strait. 

a. Superior strait. — Formed by the promontory, projecting part of 
the wings of the sacrum, innominate line of the ilium, ilio-pectineal 
eminence, pectineal surface, pubic spine, superior part of the pubis 
and of the symphysis pubis. 

Diameters. — 

1. Antero-posterior or sacro-pubic, eleven centimetres. 

2. Ttco oblique,- the left from the right sacro-iliac symphysis to 
the left ilio-pectineal eminence ; the right from the left sacro-iliac 
symphysis to the right ilio-pectineal eminence. These two diame- 
ters are equal and measure twelve centimetres. 

3. A transverse, uniting transversely the two most distant points 
of the innominate line, fourteen centimetres. 

b. The great excavation , or the Excavation, properly so-called. — 
Formed by the sacral concavity, the great sciatic notch, the os- 
seous surface extending from the ischium to the iliac wdng, the 
obturator foramen, the posterior surface of the pubis and of the 
symphysis pubis. 




Fig. 96. — Pelvis : diameters of the superior strait. 

Diameters. — 

1. An antero-posterior, from the median part of the third sacral 
vertebra to the middle of the posterior inter-line of the symphysis 
pubis, twelve centimetres. 



The Parturient Canal. 



87 



2. Tico oblique: the left, better called the ccecal, from the middle 
of the right sciatic notch to the middle of the left obturator foramen ; 
the right, better the rectal, follows an opposite direction; both 
measure twelve centimetres. However, the two extremities of these 
diameters, corresponding to soft parts, are easily extended to 
thirteen centimetres, and even more. 

3. A transverse: from a point corresponding to the base of one 
cotyloid cavity to that of the other, twelve centimetres. 

c. The median strait. — Formed by : the inferior part of the sacrum, 
the inferior border of the lesser sacro- sciatic ligament, the sciatic 
spine, a line from this spine to the inferior part of the pubic 
symphysis. 




Fig. 97. — Pelvis : diameters of the excavation. 

Diameters. — 

1. An antero-posterior, from the inferior and median part of the 
sacrum to the inferior part of the symphysis pubis, twelve centi- 
metres. 

2. Two oblique: a ccecal, from the middle of the right lesser sacro- 
sciatic ligament to the middle of the ischio-pubic border and of the 
left obdurator foramen ; a rectal, identical in the opposite direction. 
Both measure eleven centimetres. 

3. A transverse: extending from the sciatic spine of one side to 
that of the opposite, ten centimetres. 



d. e. Lesser excavation and inferior strait. — I unite these two regions 
in one description. Their importance is only secondary in relation 
to the preceding. The inferior strait, according to classical de- 
scriptions, is constituted by the point of the coccyx, the inferior 
border of the great sacro-sciatic ligament, the ischium, the ischio- 
pubic rami and the inferior part of the symphysis pubis. Now I 
shall remark : 

1. That the great sacro-sciatic ligament does not extend to the 
point of the coccyx, but from the base of this bone to the ischium, 
so that the inferior strait is without limit in this region. 



88 



The Parturient Canal, 



2. That the coccyx, from its mobility, plays the role of a soft 
part, its point consequently cannot serve to limit a fixed osseous 
strait, this would only be possible in ankylosis of the articulation of 
this bone with the sacrum, a pathological condition and relatively 
rare. 




Fig. 98. — Pelvis: diameters of the median strait. 

3. That the line uniting the ischiatic bones is found much above 
that going from the point of the coccyx to the inferior part of the 
symphysis pubis, and that for this reason these parts cannot con- 
tribute to the formation of a single plane. 

4. That the coccy-perinaeal muscle by its insertion rises above 
the inferior strait and removes almost all its importance, in an 
obstetrical point of view. 



These different reasons argue for the acceptance of the median 
strait as the real limit of the excavation inferiorly. It conforms 
better to the reality to consider the inferior strait, not as a true 
strait, but as a simple osseous tripod, formed by the two ischiatic 
bones and the coccyx, these three projections being separated by 
three deep notches, the pubic in front, the sacro-sciatic laterally. 
It is comprehended then that a displacement (of the ischiatic bones) 
and a fixation (coccyx) may become a cause of dystocia. Thus it 
is well to know that in the normal state the distance which separates 
the two ischiatic tuberosities is eleven centimetres, and that which 
usually extends from the point of the coccyx to the inferior part of 
the symphysis pubis is nine centimetres, but is very extensible. 

Placing in relation the dimensions of corresponding diameters we 
have : 



Diameters. 


Transverse. 


Oblique. 


Antero-posterior 


Superior strait 


13 


12 


II 


Excavation 


12 


12 


12 


Median strait 


10 


II 


12 



The Parturient Canal, 89 

It will be seen then, by recalling that in the excavation the oblique 
diameters present a notable extensibility, that the great dimensions 
of the pelvis are : 

Transverse at the superior strait. 

Oblique in the excavation. 

Antero-posterior at the median strait. 

We can now, from these figures, foresee the situation of the foetal 
head in its descent through the osseous canal. The head will place 
its greatest dimension, that is, the occipito-mental diameter, so that 
its position will be : 

Transverse at the superior strait. 

Oblique in the excavation. 

Direct at the median strait. 

II. Soft pelvis. — PerincBum. — The pelvic skeleton constitutes one 
of the most important muscular centers. Of these muscles some 
descend from the thorax to an insertion on its upper border; others 
are inserted on its external surface ; finally, the last, which interest 
us more especially, are fixed to the internal surface of the pelvis, 
lining its walls and closing its inferior opening. Let us follow the 
latter muscles from the superior toward the inferior part of the 
pelvis. Above the superior strait, filling the iliac fossae, are the 
psoas muscles, which we have already had in question. Below the 
superior strait, after having raised the pelvic aponeurosis, which 
forms a fibrous mass solidly closing the pelvis below, is found a 
most important muscular plane, lining the pelvis and also closing 
it below. The muscles thus uncovered (Fig. 99) are posteriorly 
the pyramidals ; laterally and in front, the internal obturators, and 
finally, in the center of this large space is found the coccy-perinaeal 
elevator, which it would be more simple to call the levator perinsei. 
The internal obturator passes, from its. insertion around the 
obturator foramen, between the sciatic spine and the ischium to 
become fixed in the great trochanter. The pyramidalis, from its 
origin on the anterior and lateral surfaces of the sacrum, passes 
out through the great sacro- sciatic notch to become fixed on the 
great trochanter also. The coccy-perinseal elevator, or simply the 
peringeal, forms a trough, a hammock, transversely in the pelvis, 
attached laterally to the sciatic spine, to the pubis and to a fibrinous 
intersection which unites these two points. Posteriorly it is 
attached to the coccyx and to the inferior part of the sacrum 
while it is free in front and is limited by the posterior vaginal wall. 
It is on this hammock that the organs of the pelvis rest. This 
hammock supports the foetal head, which depresses it in its passage 
to the vulvar orifice. 

The levator possesses several fasciculi which by their union con- 
stitute one muscle. The first fasciculus, the ischio-coccygeal, 



90 



The Parturient Canal. 



extends from the sciatic spine to the lateral parts of the coccyx. 
The second fasciculus, the coccygeal, arising from the fibrous inter- 
section between the sciatic spine and the pubis, has its fibres con- 
verging toward the point of the coccyx. The third fasciculus, the 
ano- vulvar, particularly resisting, arises in front at the inferior 
and posterior part of the pubis and forms a fan interlacing with 
the fibres of the opposite side, between the coccyx and anus for one 
part and the rectum and vagina for the other part; some fibres 
terminating on the lateral portions of the rectum and vagina. 



Urethra 
Obturator 
foramen, 

Vagina 



Rectum (anus) 




Ilium. 

Ano-vulvar 
fasciculus. 

Internal 
obturator. 

Coccygeal 
fasciculus. 

Ilium. 



Ischium coccy- 
geal fasciculus. 

Pyramidal. 



Sacrum. 



Fig. 99. — Pelvic diaphragm. Internal obturators. Pyramidial muscles. 
Coccy-perinseal elevator. 

Examined as a whole, the fibres of this levator may be divided into 
three fans on each side, disposed in opposed directions : a sciatic 
fan, with the point at the sciatic spine and the base at the lateral 
border of the coccyx; a coccygeal fan, with the point at the 
extremity of the coccyx and the base at the fibrous intersection join- 
ing the sciatic spine and the pubis, and a pubic fan, with the point 
at the pubis and the base on the coccy-vulvar median line. 

The coccyx is thus included in the muscle and forms a de- 
pendent portion. This bone, being mobile at its articulation with the 
sacrum, follows the fibres in their different movements. Thus, when 
the foetal part distends the muscular mass the coccyx is pushed 
backward with the muscular fibres. This bone, a hard part in the 
static state, should be considered as a soft part in the dynamic 
state. This pushing back of the coccyx makes a portion of the 
amplification of the perinaeum. It marks the beginning of the period 
of expulsion. It is the first obstacle met by the foetal part at the 
beginning of this period. But this obstacle will usually be easily 
overcome, unless there is ankylosis of the sacro-coccygeal articu- 
lation. There then exists a veritable cause of dystocia. 

The anterior portion of the levator perinaei, the part in contact 
wdth the posterior vaginal wall, may also become a cause of dystocia. 



The Parturient Canal. 



91 



Budin, who has particularly studied this cause of dystocia, has 
clearly established the fact that this anterior portion of the levator 
may be an obstacle to exploration, to coitus, and to delivery. 



.5^ 



3. 


V 


3 


> 


P. 


ui Pi 


O 


■u " 




o « 




i;j= 



■c « 




Bulbusvestibuli 



Ischio-cavern- 
ous muscle. 



Desptransverse 



Superficial 
transverse. 



External 

sphincter of the 

anus. 



Fig. ioo.~ Schema representing the superficial muscles of the perinasum. 

Thus constituted the levator perinsei is to the abdominal canity 
(at the inferior pelvic opening) what the diaphragm is to the inferior 
thoracic opening. The perinaeal elevator is covered and completed 
superficially by a series of muscles, which must be described in 
brief. Of these muscles, one surrounds the termination of the 



92 



The Parturient Canal, 



intestine ; this is the external sphincter of the anus. The others 
are disposed around the vulva. They are : 

1. The constrictor of the vulva, a muscular ring enveloping the 
vaginal bulbs. Its contraction produces inferior vaginismus. 

2. The superficial transverse muscle, a muscular band thrown 
from one ischium to the other. 

3. The deep transverse muscle, "a simple muscular vestige pass- 
ing from the ischio-pubic ramus to the corresponding bulb of the 
vagina. 

4. The ischio-cavernous muscle, enveloping, along the ischio- 
pelvic rami, the root of the cavernous bodies. 

5. Wilson's muscle, composed of some muscular fibres passing 
from the internal surface of the pubis to the urethra. 




Fig. ioi. — Antero-posterior section of the muscles and aponeuroses of the perinaeum 
(Schema). MW, Wilson's muscles; T P, deep transverse; CV, vulvar constrictor; 
TS, superficial transverse; R C P, coccy-peritonaeal elevator; S A, anal sphincter 
(external sphincter). 

Thus we have two muscular planes constituting the perinaeum : 
A deep plane, consisting of the perinseal elevator, which is, conse- 
quently, the pelvic diaphragm ; a superficial plane, represented by 
the muscles subjacent to the skin. Through these tissues pass 
vessels and nerves. Thus comprised, the perinaeum gives passage 
to three important organs, the rectum behind, the urethra in front 
and the vagina in the middle. To terminate the study of the geni- 
tal canal there remain for description the vagina and its appendage, 
the vulva. 



The Parturient Canal. 



93 



The vagina is a canal of cylindrical form, inserted by its superior 
extremity on the cervix, forming the culs-de-sac, and continues at 
its inferior extremity with the vulva at the level of the hymen. Its 
length is ten centimetres, measured to the posterior cul-de-sac. Its 
external surface is in relation to the surrounding viscera, the rectum 
behind, the bladder in front; and inferiorly, muscular relations 
with the pelvic floor. Thus the vagina forms a large and spacious 
cavity in the vicinity of the uterus and becomes narrowed at the 
vulva. 



Praeputium clitoridis 
Clitoris, 

Labia majora. 13 

Labia minora. 
Urethral tubercle and 
urethra. 

Vaginal orifice. 

Hymen. 

Fossa navicularis. 



Perinaeum, 



Anus. 




Mons veneris. 
Labia majora. 



Orifice of Bartholin's 
gland. 



Fourchette. 



Fig. I02. — Virginal vulva. 

In exploring the internal surface of the vagina, by separating the 
two walls, it is found to have a rosy tint, in the normal state ; a 
violaceous during pregnancy. On both the anterior and posterior 
walls exists a longitudinal projection called the vaginal column 
(anterior and posterior). 

The vagina is composed of three coats : an external, composed of 
connective tissue and elastic fibres ; a middle, of non-striated mus- 
cular tissue, of which the eccentric fibres are longitudinal, and the 
concentric circular, an internal, mucous, totally deprived of glands 
but rich in papillae that are covered by stratified pavement epithe- 
lium. 



94 The Parturient Canal, 

The vulva is composed of three successive and concentric planes : 
FiEST PLANE. — Mons Veneris, labia majora, perinceiim. — The labia 
majora form two vertical folds, blending above with the mons 
veneris, and becoming effaced below on the perinseum. In the 
center of the oval thus formed are found the other vulvar parts. 
The external surface of the labia is cutaneous and covered with 
hair ; the internal surface is smooth, normally moist and the two 
labia are often in contact. This contact is destroyed by the 
separation of the thighs. 

Second plane. — Prceputimn clitoridis, nymphce, fourchette. — The 
nymphse are two folds analogous with and parallel to the labia 
majora, but much more thin. Above they separate to enclose the 
clitoris. Of the two folds formed by this separation, one forms the 
prepuce of the clitoris, the other forms the fraenum. Below, the 
nymphse diminish, and are united by a small fold called the 
fourchette. 

Vagina. 

Post-navicular commissure. 

Navicular fossa. 

Anterior navicular commissure 

Ano-vulvar perinaeum. 




AnuL 



Fig. 103. — Perineo-vulvar profile. 

Thibd plane. — Vestibule, meatus urinarius and its tubercle, vagina 
and hymen. — In the space circumscribed by the base of the nymphae 
is found an elliptical surface that can be considered as divided into 
two equal parts by a transverse line. Above this line is the 
vestibule, below it is the vagmal orifice. The vestibule presents 
the urethral tubercle with the meatus urinarius. The vaginal 
orifice, below this, is more or less protected by the hymen, or the 
carunculae which represent its remains. The fossa navicularis is a 
small depression situated between the fourchette and the hymen or 
its debris. Laterally the fossa navicularis is lost on the sides of 
the vulva : anteriorly and posteriorly it is limited by the anterior 
and posterior navicular commissures (Fig. 103). The vulva is 
separated from the vagina by the hymen. The intact hymen may 
present various conformations (Figs. 104 to 111). At the first coitus 
the hymen is usually ruptured, leading the hymeneal carunculse 
(Fig. 112). After accouchement, these ruptures become deep and 
by isolated cicatrization form the carunculae myrtiformes (Fig. 
113). In rare cases the hymen may remain intact after coitus, and 
even after parturition. In exceptional cases, pregnancy has been 
noted with an imperforate hymen. 



The Parturient Canal. 



95 



Resume of the parturient canal. — Planes and axes. — The parturient 
canal, consisting, as has been seen, of an osseous passage and of 
a soft passage, is somewhat modified in its osseous portion by the 
presence of soft parts which retract the different diameters of the 
pelvis, but which, nevertheless, do not alter the general form. 






Fig. 104. — Crescent hymen. 



Fig. 105.— Hymen with 
a small diaphragm. 



Fjg. 106. — Hymen with 
a large diaphragm. 






Fig. 107. — Cleft hymen. Fig. 108. — Fringed hymen. 



Fig. 109. — Hymen with 
double slit. 





Fig. iio, — Hymen with a 
double orifice. 



Fig. III. — Cubiform hymen. 





Fig, 112. — Hymeneal carunculoe. 



Fig. 1 13, — Carunculse myrtiformes. 



The plane of the superior strait, with the woman in the erect 
position, forms an angle of sixty degrees with the horizontal. The 
plane of the inferior strait is more closely approached to the hori- 
zontal, but without coinciding with it. This difference of inclination 
is due to the unequal hight of the pelvic walls, which, in front 



96 



The Parturient Canal. 



(pubis) measure five centimeters, and behind (sacrum) ten cent 
metres. 

The axis of the superior strait, that is the perpendicular to the 
center of its plane, passes from the umbilicus toward the middle 
of the coccyx. That of the median strait extends from a point 
situated a little in advance of the promontory toward the anus. 
The direction of the axis of the pseudo inferior strait is quite 
variable on account of the mobility of the coccyx. The direction of 
these axes is very important in practice, for they indicate the 
direction in which the tractions on the foetus should be made. 




Fig. 114. — Fish-hook curve of the parturient canal. 

The general axis of the parturient canal, from the superior strait 
to the vulva, is not an arc of a circle, as described by Carus, nor an 
angle, as maintained by Fabbri, but rather a fish-hook, as Tarnier 
has indicated, that is, rectilinear in the osseous portion and curved 
in the arc of a circle in the soft parts (Fig. 114). This curve is of 
the greatest interest to the obstetrician, as will be seen later. 



Presentations and Positions, 97 



CHAPTER V. 



PRESENTATIONS AND POSITIONS. 

Presentations. — The foetus, enclosed in the uterine cavity, is 
separated from the exterior by the parturient canal, which it must 
traverse at the moment of labor. For this exit, it may be placed 
in different way s, ^rese?i^m^ to the genital opening so many different 
regions of the body. The symptoms furnished by foetal exploration 
and the mechanism of delivery, will necessarily vary according to 
these different cases. The necessity of a classification of the foetal 
presentations is thus imposed on obstetricians. Eolled up in the 
uterine cavity, the child is generally flexed. This general flexion 
is accomplished by a series of partial flexions. Thus, the head is 
flexed on the trunk, the forearms on the arms, the hands on the 
forearms, the thighs on the trunk, the legs on the thighs, the feet 
on the legs— flexion everywhere. In this attitude, which singularly 
favors the reduction of the foetal mass, the child offers the form of 
an ovoid, the large extremity corresponding to the breech and the 
small extremity to the head. This is the somatic ovoid. The somatic 
ovoid (Fig. 115) is divided, as explained before, into the cephalic 
ovoid and the cormic ovoid. 




Fig. 115. — Somatic ovoid lormed by the union of the two ovoids, 
cephalic and cormic. 

The cephalic ovoid, though smaller than the cormic ovoid, is less 
reducible. Its great axis extends from the chin to the sagittal 
suture, a little in advance of the lambda. Considered in its trans- 
verse dimensions, it presents a series of points serving as marks of 



98 



Presentations and Positions. 



other diameters ; these are the biparietal, bifrontal, bimalar and 
biasteric. 

The cormic ovoid, more or less deformed by the addition of the 
superior and the inferior members, presents its great diameter from 
the breech to the summit of the thorax. ' It also offers transverse 
diameters, such as the bisacromial and bitrochanteric. These two 
ovoids are united by the neck. 






Fig. 1 1 6. — Vertex 
presentation. 



Fig. 117. — Face 
presentation 



Fig. 1x8. — Brow 
presentation. 




Fig. 119. — Breech presentation. FiG. 120. — Thorax presentation. 

The foetus presents at the genital canal, usually by the cephalic 



Presentations and Positions, 99 

ovoid, sometimes by the cormic ovoid. But every ovum, to pass 
through the parturient canal, may open it by the large or by the 
small extremity, or, again, transversely. Theoretically, there are, 
then, three presentations for every ovoid : large end, small end, and 
transversely. The same is true with regard to each of the foetal 
ovoids. 




Fig. 121. — Abdomen (lumbar) presentation. 

The cephalic ovoid may, in fact, present : 

1. Sometimes by its large extremity (vertex) (Fig. 116). 

2. Sometimes by its small extremity (face) (Fig. 117). 

3. Sometimes transversely (brow) (Fig. 118). 

The cormic ovoid also may present : 

1. Sometimes by its large extremity (breech) (Fig. 119). 

2. Sometimes by its small extremity (thorax or shoulder) 
(Fig. 120). ^ 

3. Sometimes transversely (loins or abdomen) (Fig. 121). 

We have then six presentations : 

Cephalic ovoid. Cormic ovoid. 

1. Vertex. i. Breech. 

2. Face. 2. Thorax (shoulder). 

3. Brow. 3. Abdomen (loins). 

The vertex and the breech are identical ; they represent the large 
extremity : one the cephalic ovoid ; the other the cormic ovoid. The 
face and the thorax are analogous, they represent the two small 
extremities. The analogy is the same for the brow and the lumbo- 
abdominal region; the ovoids are placed transversely. 

Of the six presentations, each comprise one of the zones of the 
two foetal ovoids limited by the following planes : For the cephalic 
ovoid, two planes perpendicular to the long axis of the head, passing, 
one through the root of the nose, the other through the posterior 
angle of the bregma. For the cormic ovoid, two planes, also per- 
pendicular to the long axis, and passing, one through the summit 
of the iliac crests, the other through the point of the zyphoid ap- 
pendix (Fig. 122). 



100 



Presentations and Positions. 



Eelative frequency of these different presentations : 



Vertex, - 19 out of 20 parturitions. 

Face, - - I " 250 

Brow, - - I " 300 " 

Breech, - i " 30 " 

Thorax, - i " 125 

Abdomen, i " looo " 



" (Relatively too high) 

The following proportions may also be adopted. Out of one 
thousand parturitions there exist : 



Vertex, 
Face, - - 
Brow, - - 
Breech 
Thorax, - 
Abdomen, 



956 deliveries. 
4 
3 

30 
6 
I 



(I recall again that 1 to 1000 for the abdomen is relatively too 
high.) 




^ . . . , r I- Vertex. 

Occipito - mental J jj Face, 
portion. [m] g^ow^ 



Pelvi -cervical 
portion. 



I. Breech. 

II. (Shoulder) Thorax. 
III. Back and abdomen. 



Fig. 122. — Schema of presentable zones. 

Each of these six presentations has four varieties. These varieties 
are of secondary importance to the cephahc ovoid, and only indicate 
a simple inclination of the fcetal part which presents. A simple 
enumeration will be sufficient : 



I. Vertex. — Variety, 



Occipital (exaggerated flexion). 

Frontal (flexion little marked). 

Right parietal fright parietal quite accessible). 

Left parietal (left parietal quite accessible). 



Presentations and Positions. 



101 



II. Face. — Variety, 



III. Brow. — Variety, 



Mental (extension). 

Frontal (extension not marked), 
j Right malar (right malar quite accessible). 
[ Left malar (left malar quite accessible). 

f Parietal (tendency to flexion). 
J Facial (tendency to extension). 
I Right temporal (right temporal quite accessible). 
[ Left temporal (left temporal quite accesible). 



For the cormic ovoid, on the contrary, these varieties are im- 
portant, for they lead to practical consequences that will be studied 
later. 




Fig. 123. — Complete breech. 

I. Breech, — 

1. Complete variety. — The inferior limbs are flexed and close to the 
pelvis. This is the type for presentation of the breech (Fig. 123). 

2. Incomplete variety. — Thighs. — The pelvic members are raised 
up along the anterior plane of the foetus (Fig. 124). 

3. Incomplete variety. — Knees. — The thighs are extended, but the 
legs flexed on the thighs, so that the knees constitute the lowest 
foetal part (Fig. 125). 

4. Incomplete variety. — Feet. — The inferior limbs are extended, 
and the feet descend first (Fig. 126). 



II. Thorax. — 

1. Variety of the right shoulder (that is, the region of the right 
shoulder presents.) 

2. Left shoulder. 

3. Back (thoracic portion). 

4. Sternum. 



102 



Presentations and Positions, 



Thus one of the four surfaces of the thorax presents (anterior, 
posterior, right or left lateral). 



I 




Fig. 124. — Incomplete breech, thigh variety. 

III. Abdomen, — 

1. Variety of the right flank. 

2. Left flank. 

3. Lumbar regions. 

4. Umbilicus. 




Fig. 125. — Incomplete breech, knee varrety. 

Thus, as for the thorax, the variety is constituted by the region 
of the abdomen (anterior, posterior, right or left lateral) presenting. 



Presentations and Positions, 



103 



I present the following table, placing the figures relative to each 
presentation and their varieties, which indicate the frequency. 




Fig. 126. — Incomplete breech, foot variety. 



I. Vertex, 956 per 1000. 





Variety, ^ 


Occipital, . - - 
Frontal, - - - 
Right Parietal, 
[ Left parietal, 


- (?) 

- (?) 

- (?) 

- (?) 




11. 


Face, 4 per 1000. 








Variety, - 


Mental, ... 
Frontal, - . - 
Right malar. 
Left malar, 


- (?) 
■ (?) 

- (?) 

- (?) 




Ill 


. Brow, 4 per 1000. 








f Parietal, - - - 

1 F3,C13.1 - - • • 

^^''^'y^ i Right 'temporal, - . 
[^ Left temporal. 


- (?) 

- (?) 

- (?) 

- (?) 




IV. 


Breech, 30 per 1,000. 








f Complete, ... 
Variety, \ Incomplete, thighs, . 
•^ ' j Incomplete, knees, 
1^ Incomplete, feet. 


450 per 
300 " 

5 ". 
245 " 


1000 

(( 


V. 


Thorax, 6 per 1000. 








f Ri^ht shoulder, 
[ Sternum, 


500 per 

495 " 
3 " 
2 " 


1000 
(. 

n 

« 


VI. 


Abdomen, 1 per 1000. 








Variety, 


' Right flank, - 
Left flank, 
Lumbar regions. 
Umbilicus, 


- (?) 
. (?) 

- (?) 

- (?) 





104 Presentations and Positions. 

Causes of the presentations. — Accommodation, or adaptation of 
the contained foetus to the containing uterus, regulates the situation 
of the child during pregnancy. The laws of this accommodation 
are two in number and may be formulated thus : 

First law (uterine law). — Every contractile containing body adapts 
to its own form and dimensions its contents even inert, provided it 
is sufficiently resisting (that is, accommodation can be made with 
a foetus recently dead). 

Second laic (foetal law). — Every living contents, endowed with 
active movements, adapts its forms and dimensions to those of a 
containing body even inert, provided it is sufficiently resisting. 

Now, these two essential conditions of accommodation will be re- 
united : with a firm and contractile uterus ; with a vigorous and 
moving foetus. The general form of the foetus is, as we have seen, 
that of an ovoid, with the large extremity corresponding to the 
breech, the small extremity to the head. The general form of the 
uterus is that of an ovoid, with the large extremity corresponding to 
the fundus, the small extremity to the inferior segment. Accom- 
modation brings the breech of the foetus to the fundus of the uterus 
and the head in the inferior segment. 

We now know why the foetus normally presents by the vertex. 
Let us review the various causes which modify this physiological 
state and cause other presentations. We shall need to examine 
successively the pelvis, the uterus, the ovuline appendages and the 
accidental causes, such as traumatism. 

1. Pelvis. — In the normal state, with a presentation of the vertex, 
the head during the latter part of pregnancy engages in the pelvic 
excavation. This engagement, by fixing the foetal part, assures the 
preservation of the presentation. But when any cause (contraction 
of the pelvis, pelvic tumor) renders difficult or impossible the passage 
of the superior strait, the head remains mobile and the foetus, not 
being fixed, is exposed to mutations of presentation. 

2. Uterus. — Normal accommodation in presentation of the vertex 
supposes a uterus sufficiently resisting and of an ovoid form with 
the small extremity inferior. Any exaggerated flexibility of the 
uterus, or any alteration of its normal form, becomes a cause of 
vicious presentations. 

By this mechanism act : 

Excessive multiparity; by causing a relaxation of the uterine 
wall, and of the abdominal wall which sustains it. The foetus re- 
mains mobile to the moment of delivery, and in one of its evolutions 
may become fixed in a vicious presentation. 

Lateral and anterior inchnations of the uterus ; these inclinations, 
whether real or apparent, nivolve the foetus in their deviation, so 
that its axis no longer corresponds with that of the pelvis. The 
result is seen in vicious presentations. 



Presentations and Positions, 



105 



Bifidity of the fundus of the uterus, the vestige of a double uterus, 
causes, when it is marked, presentation of the thorax or abdomen. 
Less pronounced bifidity produces either a breech presentation or 
one of the three presentations of the cephalic ovoid, on account of 
the direction of the pressure on the vertebral column. I shall 
explain: The head being articulated with the vertebral column so 
that the point of the occiput and the chin are at an equal distance 
from the vertebral foramen, when the pressure transmitted by the 
vertebral column to the head is made in the direction of the occiput, 
the cephalic extremity is flexed (vertex presentation) ; it is extended, 
on the contrary, when this pressure is directed toward the chin 
(face presentation) , and, finally, it remains intermediate between 
flexion and extension when the pressure is directed toward an inter- 
mediate point, the forehead (brow presentation) (Figs. 127, 128, 129). 






Fig. 127. Fig. 128. Fig. 129. 

Fig. 127. — Genesis of the vertex presentation. Foetus in LO I T. Breech fixed in 
the right cornu. Pressure of the vertebral column transmitted toward the occiput. 

Fig. 128. — Genesis of the face presentation. Foetus in LOIT. Breech fixed in 
the left cornu. Pressure of the vertebral column transmitted toward the chin. 

Fig. 129. — Genesis of the brow presentation. Foetus in LOIT. Breech fixed on 
the median line cf the abdomen. Pressure of the vertebral column transmitted toward 
the brow. 

A reverse development of the uterus, that is, of the inferior 
segment greater than that of the fundus, giving the form of an ovoid 
with its large extremity below, causes a breech presentation. 
Finally, tumors of the uterus or in its vicinity, altering its normal 
form, may be the source of vicious presentations. 

3. Foetus. — Any cause altering the gen'eral form of the foetus, or 
diminishing its volume or its resistance, is susceptible of producing 
a vicious presentation. We find in this category of causes : Death 
of the foetus when it dates from some previous time and when macer- 
ation has taken place — accommodation then fails to act ; smallness 
of the foetus also renders accommodation useless. Hydrocephalus, 



106 Presentations and Positions. 

increasing the size of the head relative to that of the breech, is a 
cause of presentation of the breech. DoHchocephalus has been 
regarded by Hecker as a cause of presentation of the face, but it 
is demonstrated to-day that dohchocephalus is, except in some 
cases, secondary to delivery by the face, and is not primary. 
Exaggerated size of the foetal head will be, according to Spiegelberg, 
a cause of face presentation. This explanation is quite admissible, 
for it acts the same as a narrowing of the pelvis. Some tumors of 
the foetus, tumors of the neck, or of the occiput, causing extension 
of the head and obstructing descent, may also produce brow or 
face presentations. Among the exceptional causes of vicious 
presentations, are found muscular retractions (congenital torti- 
colis). I simply mention multiple pregnancy and monstrosities. 
Their influence on accommodation will be easily comprehended. 

4. OvuUne appendages. — Three causes on the part of the ovuline 
appendages may produce vicious presentations : Placenta praevia 
by preventing engagement of the vertex thus favors a breech or 
thorax presentation. Hydramnios, by distending the uterus, 
prevents accommodation. In such cases breech or thorax presen- 
tations are frequently seen. Finally, loops of the cord around the 
foetal neck may retain the head of the child toward the fundus. 

5. Traumatism. — Traumatism acting on the hypogastrium, may 
displace the foetal head and be the source of a vicious presentation. 
This cause may be admitted, but it is wholly exceptional. 

Peculiarities of each presentation. — Presentations are definitive or 
temporary, according as the foetal part is fixed or momentarily 
arrested in the genital canal. 

In general, the definitive presentations are those where engage- 
ment has taken place during pregnancy, and the temporary those 
on the contrary, where the foetal part remains mobile at the 
superior strait. We shall see, however, that there are some ex- 
ceptions. 

Vertex. — In the absence of an abnormal condition, when there 
is a vertex presentation, engagement occurs during the last three 
months in the primiparse, and during the last fifteen days in the 
multiparse. With engagement, the presentation becomes definitive. 

Face. — Presentations of the face are exceptional during preg- 
nancy ; however, some cases have been observed. Ordinarily they 
occur at the moment of labor. Presentations of the face existing 
during pregnancy, are called primary. The secondary are those 
formed during labor. These presentations become definitive only 
when engagement occurs, that is at an advanced period of labor, 
for engagement never takes place during pregnancy nor at the 
beginning of labor. 



Presentations and Positions. 107 

Broio. — What has been said with regard to face presentations, 
exactly applies to those of the brow. 

Breech. — Presentation of the breech, like that of the vertex, may 
exist long before labor. During pregnancy there may be observed 
a complete presentation of the breech or an incomplete, of the 
variety of the thigh ; the two other varieties (knees and feet) only 
appear at the moment of labor. When the breech is incomplete, 
thigh variety, it often engages in the last part of pregnancy, and by 
this engagement becomes definitive. But when the breech is 
complete, its volume prevents engagement; and yet the presen- 
tation is often definitive without engagement, for the cause which 
produces this vicious presentation prevents the foetus from changing 
its position. In this case, as in the preceding with engagement, 
there are sometimes found serious difficulties in performing version 
by external manoeuvres. 

Thorax. — Presentations of the thorax exist during pregnancy as 
at the moment of labor, but they are rarely definitive during ges- 
tation, unless a special form of the uterus fixes the foetus in this 
vicious situation. The engagement of the shoulder (much the most 
frequent variety) never occurs during pregnancy, and only takes 
place at an advanced period of labor. At this moment, or when 
after the flow of the liquor amnii the uterus is retracted, the presen- 
tation becomes definitive, and is much more difficult to correct, as 
considerable time has elapsed. 

Presentations of the abdomen are subject to the same consider- 
ations as those of the thorax. 

Positions. — When we examine completely and in detail a statue 
placed on a mobile pedestal, we turn it to note successively the 
face, the three-quarter view (anterior), the profile, the three-quarter 
(posterior), the back ; then, by continuing the movement of rotation, 
the three-quarter view (posterior), the profile, the three-quarter 
(anterior), and finally the face, the statue now ha^dng returned to 
the starting point. Now, the foetus, whatever may be the presen- 
tation, may execute in the uterine cavity an analogous evolution, 
an evolution during which, without changing the presentation, it 
will offer a series of new situations. To those different situations 
we give the name of jjositions. The importance of clearly dis- 
tinguishing positions from presentations is then seen. The presen- 
tation is constituted by the foetal region which descends first into 
the parturient canal. The position is tlie situation of the foetal 
region which presents. We know the presentations, let us study 
the positions. 

To designate the different positions, there has been chosen for 
each presentation a foetal point or land-mark, which, by its relations 



108 



Presentations and Positions. 



with other points taken on the parturient canal, permits the 
determination of the exact situation of the child. I shall explain 
by an example : A foetus presents by the vertex (I take the occiput 
as a landmark), the occiput may, according to the situation of the 
child, be in relation with the pubis, with the sacrum, or with other 
regions of the pelvic ring, thus we should have an occipito-pubic 
position (contact of the foetal occiput and the maternal pubis), an 
occipito-sacral (contact of the foetal occiput with the maternal 
sacrum), etc. 
1. — Foetal points , 

I. Vertex - - Occiput 
11. Face - - Mentum 

III. Brow. - - Mentum 

IV. Breech - - Sacrum 
V. Thorax - - Acromium 

VI. Abdomen - - Acromium 



0. 
M. 

M. {Id. as for face), 

S. 

A. 

A. {Id. as for thorax). 



f? 



LIT» 




•RIT 



Fig. 130. — Rosette of positions. 

2. Maternal points. — There have been taken on the contour of the 

pelvic ring the terminal points of the different diameters. These 
points are the following : 

Point. — Pubic - - - - - - P. 

Eight anterior iliac - - - K A I. 
Eight transverse iliac - - - E T I. 
Eight posterior iliac - - - E P I. 
Sacral - - - - - S. 

Left posterior iliac - - - L P I. 
Left transverse iliac - - - L T I. 

Left anterior iliac - - - LAI. 



Presentations and Positions. 109 

As a whole these points, m comparison with a manner's compass, 
may be called the compass of the positions. 

Now for each position let us put the foetal point in relation with 
ditferent maternal points and we shall have the series of positions 
which follow : 

I. Vertex {Occiput). — 0. 

Position. — Occipito-pubic 

Plight anterior occipito-iliac 

Eight transverse occipito-iliac 

Eight posterior occipito-iliac 

Occipito-sacral 

Left posterior occipito-iliac 

Left transverse occipito-iliac 

Left anterior occipito-iliac 

IL Face (Mentum). — M. 

Position. — Mento-pubic - - - 
Eight anterior mento-iliac - 

I. Ve7iex (Occiput). — 0. 

Position. — Occipito-pubic 

Eight anterior occipito-iliac - 

Eight transverse occipito-iliac 

Eight posterior occipito-iliac 

Occipito-sacral 

Left posterior occipito-iliac - 

Left tranverse occipito-iliac - 

Left anterior occipito-iliac 

IL Face (Mentum).— M. 

Position. — Mento-pubic 

Eight anterior mento-iliac 

Eight transverse mento-iliac ■ 

Eight posterior mento-iliac 

Mento-sacral 

Left posterior mento-iliac 

Left transverse mento-iliac - 

Left anterior mento-iliac 

III. Brow (Mentum).— M. 
Id. as for the face. 

IV. Breech (Sacrum). — S. 

Position. — Sacro-pubic - - - - S P. 

Eight anterior sacro-iliac - E S I A 3. 

*The figure following the oblique positions indicates their relative frequency, the 
figure I representing the most frequent, which has been called the first position of the 
vertex. 



OP. 


EO A 13.* 


ET 1. 


E0PL2. 


OS. 


L P I 4. 


L OTL 


L All. 


MP. 


EM A. 


OP. 


E I A 3.* 


EOIT. 


E I P 2. 


S. 


L I P 4. 


L OIT. 


L 01 Al. 


M P. 


EM I A. 


EMIT. 


E M I P. 


M S. 


L M I P. 


L M I T. 


L M I A. 



no 



Presentations and Positions, 



Eight transverse sacro-iliac - 

Eight posterior sacro-iHac 

Sacro-sacral 

Left posterior sacro-iliac 

Left transverse sacro-iHac 

Left anterior sacro-iliac 

V. Thorax (Acromium). — A. 

Position. — Acromio-pubic 

Eight anterior acromio-iliac - 
Eight transverse acromio-iliac 
Eight posterior acromio-iliac - 
Ac romio- sacral 
Left posterior acromio-iliac - 
Left transverse acromio-iliac 
Left anterior acromio-iliac - 

VI. Abdomen {Acromium). — A. 
Id. as for the thorax. 



ESIT. 


ESIP2 


ss. 


L SIP4 


L SIT. 


L SI A 1 


A P. 


E A I A.* 


EAIT. 


EAIP. 


AS. 


L AIP. 


L AIT. 


L AI A. 




Fig. 131.— LOIT. 

To render complete and intelUgible this enumeration of the 
positions in the different presentations, I have adjoined a series of 
illustrations showing the situation of the foetus in these different 
cases (except the brow presentations which take the same situations 



*For the frequency of the positions of the thorax, it is sufficient to know that the 
dorso-anterior are more frequent than the dorso posterior. 



Presentations and Positions, 



111 



as for the face, by slightly flexing the head and by assuming a 
position intermediate between a vertex and a face presentation ; and 
abdominal presentations, which occupy the same situation as for 
the thorax, by slightly drawing the thorax away from the center of 
the genital canal, so as to replace it by the abdomen). 




Fig. 132.— ROIT. 




Fig. 133.— L O I a. 



112 



Presentations and Positions, 




Fig. 134.— LOIP. 




Fig. 135.— ROIA. 



Presentations and Positions. 



113 




Fig. 136.— R O I p. 




Fig. 137. 



114 



Presentations and Positions. 




Fig. 138 




Fig. 139.— R MIT. 



Presentations and Positions. 



115 




Fig. 140.— L MIT. 




Fig. 141.— L MIA. 



116 



Presentations and Positions. 




Fig. 142.— L M I p. 




Fig. 143 — RMI a. 



Presentations and Positions. 



117 




Fig. 144.— R M I p. 




Fig. 145. 



118 



Presentations and Positions. 




Fig. 146. 




Presentations and Positions, 



119 





Fig. 149.— L S I a. 



120 



Presentations and Positions, 




Fig. 150.— LSI p. 




Fig. 151.— RSI a. 



Presentations and Positions. 



121 




Fig. 152.— RSI p. 




Fig. 153.— LSI T. 



122 



Pi'esentations and Positions, 




Fig. 154.— R sit. 




Fig. 155.— R ait. 



Presentations and Positions, 



123 




Fig. 156.— L ait. 




Fig. 157. — LAI A. 



124 



Presentations and Positions, 




Fig. 158.— LAI p. 




Fig. 159.— RAIA. 



Presentations and Positions. 



125 




Fig. i6o.— R A I P. 




Fig. i6i. 



126 



Presentations and Positions. 




Etiology of the positions. — Vertex. — ■ The two most frequent 
positions are, first, L I A, then EOIP. It has been asked why 
the long diameter of the head voluntarily occupies the oblique 
caecal diameter, and it has been replied that this diameter is greater 
than the rectal or that the distention of the rectum diminishes the 
latter. But this explanation, which is only an hypothesis, is not 
satisfactory. It is probable that the head is found to occupy the 
oblique caecal diameter on account of the more marked development 
of the right cornu of the uterus. With regard to the predominance 
of the L I A in relation to the E I P, it responds to a law which 
regulates all the presentations : The back of the foetus, on account 
of the projection of the vertebral column posteriorly, is better 
accommodated to the anterior part of the uterus than to the 
posterior. I only speak here of the aetiology of the oblique positions, 
as they are the only ones authors generally treat of. The transverse 
and the direct positions are governed like the oblique by the form 
of the pelvis. 

Face, Brow. — Presentations of the face being only transformations 
of those of the vertex, the same ^etiological considerations apply to 
the positions. 

Breech. — The breech only rarely engagmg during pregnancy the 
question of the extent of the pelvic diameters is only secondary. 



Symptomatology of Pregnancy. 127 

The head lodging in the right cornu, the back will be placed to the 
left and in front or to the right and behind. 

Thorax, Abdomen. — During pregnancy transverse positions are 
scarcely ever found. According to the general rule the back is 
usually found to the front, in such a manner that for the left 
shoulder the RAIT is observed and the LA IT for the right 
shoulder. The accommodation of the back is the cause. 



CHAPTER VI. 



SYMPTOMATOLOGY OF PREGNANCY. 

The symptoms and signs of pregnancy may be divided into two 
great classes : those which depend on the genital system, and those 
which, on the contrary, are independent. We have, then: 1. The 
extra-genital symptoms. 2. The genital symptoms. 

I. Extra-genital symptoms. — The modifications of the different 
systems (nervous, respiratory, circulatory, digestive, etc.) have 
been previously studied, and, to avoid useless repetitions, I shall 
not return to them. 

II. Genital symptoms. — In examining the pregnant woman we 
proceed successively to : 

1. Interrogation. 

2. Inspection. 

3. Palpation (and to percussion). 

4. Auscultation. 

5. Digital examination. 

I shall conform to this order in the study of the symptoms of 
pregnancy. The symptoms furnished by interrogation respond 
very nearly to those designated as rational, and those of the four 
other categories to the physical signs. 

1. Interrogation. — The information that the woman can furnish 
as to the sexual relations, the actual cause of pregnancy, will rarely 
be of any use. Their absence in cases of doubtful diagnosis, or 
their isolated existence at a fixed date, when it relates to a precise 
statement of the epoch of pregnancy, will be the only points to seek, 
and on these points the confidence in feminine veracity should be 
limited. 



128 Symptomatology of Pregnancy. 

From menstruation, on the contrary, may be deduced signs of 
great value. 

Every arrest of menstruation in a healthy woman, normally 
regular, should bring to mind the possibility of the existence of 
pregnancy 

Conception may take place at any period of the inter-menstrual 
period or during the menstrual flow, but in the majority of cases it 
occurs during the ten days following the end of menstruation. 
From this moment of conception the menstrual flow do}s not 
appear. There are, however, exceptions, and some women continue 
to menstruate during pregnancy. It has been objected that 
menstruation during pregnancy is modified in duration, quantity or 
quahty. But, practically, the woman reports a periodical flow of 
the same abundance and quantity as before pregnancy. There is 
then nothing to show that this flow of blood differs from normal 
menstruation. It is just to conclud that this woman is menstruating 
but it must not be deduced that the uterus is empty. Conclusion: 
If the cessation of menstruation is one of the best signs of the be- 
ginning of pregnancy, we must not base an affirmation of the 
vacuity of the uterus on its persistence. 

The development of the abdomen is only perceived by the woman 
at the end of a certain stage of pregnancy (two months and some- 
times even more). Soon after conception, some women perceive a 
certain flattening of the abdomen. The development of the ab- 
domen, generally perceived clearly at the end of the fourth month, 
rarely progresses with regularity. All other things being equal, the 
development of the abdomen is as much more considerable as the 
number of pregnancies becomes greater — a fact explained by the 
increasing laxity of the abdominal walls. 

We shall ignore the exact date at which the first movements of 
the child are perceived, but we know that they are generally felt at 
the beginning of the fourth month. In general, it is at four months 
and a half that these movements are perceived, sometimes later. 
Some pregnant women never feel them. 

The descent of the uterus resulting from engagement causes pelvic 
obstruction (frequent urging to urination, exaggeration of the con- 
stipation) and a thoracic relief (easier respiration). At the same 
time the abdomen seems to diminish in volume. Women usually 
can give quite exact information on these different symptoms. 

2. Inspection. — The inspection of the abdomen and of the ex- 
ternal genital organs reveals a series of modifications, that have 
already been discussed and wliich I only recall here. On the side 
of the abdominal wall, besides the distention produced by the in- 
crease in the size of the uterus, are noted the linete albicantes, es- 
pecially numerous in the subumbilical region, and the brownish 



Symptomatology of Pregnancy , 129 

pigmentation along the linea alba. The external genital organs, 
besides oedema and varices, undergo a hypertrophy which give them 
a swollen aspect. The vestibule and the viilvo- vaginal orifice have 
a violaceous coloration that is also found en the vagina and cervix 
by using a speculum. This coloration sometimes aids the diag- 
nosis, of pregnancy, but it is not pathognomonic. Besides this, 
there is found sometimes in brunettes a diffuse pigmentation of the 
vulva, especially marked on the labia majora. 

3. Palpation. — Percussion is a variety of palpation but while 
it occupies a considerable place in medicine, its part is of slight 
importance in obstetrics. Percussion can only serve to give infor- 
mation as to the height of the uterus and on the contents of normal 
or pathological organs situated around or in front of the uterus. I 
shall not insist on these secondary ideas but pass at once to pal- 
pation itself. 

For palpation the woman should be disrobed, preserving no 
garment that will obstruct abdominal palpation. Save in rare ex- 
ceptions the horizontal decubitus is indispensable, the head a little 
elevated, the limbs extended and slightly separated from each other, 
the arms stretched along the body, all the muscles being relaxed as 
much as possible. The obstetrician should have warm liLnds, for 
a cold contact predisposes to muscular contraction. The physician 
places himself to the right of the patient and proceeds with extreme 
slowness. 

The palpation consists of three portions: (A). Prceuterine, in 
which the abdominal wall and the organs around the uterus are 
explored; (B) The uterine, where the walls of the uterus are 
examined ; (C) The Intra-uterine, in which the contents of the uterus 
are in question, that is the ovum itself in the case of pregnancy. 
Let us examine each of these in succession : 

A. Prceuterine. — The thickness of the abdominal wall will be 
appreciated by pinching it up in front of the uterus. Prceuterine 
palpation affords information as to the presence of intestinal loops 
in front of the uterus, on the degree of distention of the bladder, 
when this reservoir exceeds the superior strait. In this praeuterine 
exploration, the fingers will often feel the round ligaments, forming 
a cord quite clearly perceptible during pregnancy, especially when 
it is the seat of varices, and sometimes one of the ovaries. In this 
exploration will be recognized the tumors developing at the expense 
of the abdominal organs. 

B. Uterine. — By following the contour of the uterus, its height 
above the symphysis or above the umbilicus will be determined, an 
important observation in determining the date of the pregnancy, 
and its inclination to one side or the other of the abdomen will be 
recognized. Supple in a normal state, the uterine wall becomes 



130 Symptomatology of Pregnancy. 

resistant during contraction. In cases of excessive softness of the 
uterus, this contraction becomes necessary to afford a clear contour 
of the organ and to reveal the peculiarities of its conformation. By 
palpation the approximate thickness of the uterine wall can be 
determined. This is especially to be appreciated by the degree of 
the distance of the foetal part. Some uterine walls appear so thin 
by the superficiality of the foetus as to give the impression of an 
extra-uterine pregnancy. Uterine exploration also affords infor- 
mation on the existence of malformations and on the presence of 
fibroids. The latter, when of small size, may be mistaken for 
foetal parts, but their immobility and their preception during uterine 
contraction will avoid an error of diagnosis. 

C. Iiitra-uterine. — We arrive at the exploration of the uterine 
contents, which constitutes the third and the most important 
portion of palpation. In palpation of the ovum, many of the sen- 
sations imparted by the foetus are exact, many of those given by 
the appendages (placenta, cord, amniotic liquid) are vague. In 
exceptional cases it is possible that a special doughiness may sepa- 
rate the fingers from the foetal plane, this supposes a placenta at 
this point. I have never felt such a sensation. When the abdomi- 
nal wall is very thin the fingers may meet a cord surrounding the 
foetal trunk. The liquor amnii in normal quantity gives a fluctu- 
ation as a whole analogous to that obtained at the suiface of a large 
abscess. The foetus, however, is the principal aim of our explo- 
ration, and the hands, separated from it by the utero-abdominal 
wall, should become familiar with it. Before going further in this 
study, it is important to note two important signs that are to be 
considered as positive signs of pregnancy. I speak of passive move- 
ments and of active movements of the foetus. The first attest the 
presence of a foetus and the second indicate that the child is living. 
The first is furnished by preference by the foetal head, the second 
by the thoracic members and especially by the pelvis. 

1. Passive movements. — Usually designated as balottement these 
movements are produced in the following conditions (I suppose the 
foetal head at the fundus of the uterus, two or three fingers are 
applied mediately at its point of contact) : a. A sudden concussion 
is given to the foetal head by depressing the abdominal wall ; the 
fingers receive the sensation of a distant flying body — single sen- 
sation (of departure), h. Often, the hand being left in place, at 
the end of a few seconds the head returns to its first position and 
imparts a shock to the fingers — double sensation (of departure and 
of return), c. If the two hands are applied to the lateral extrem- 
ities of the head, the foetal head pushed suddenly by one hand gives 
a sensation of departure, comes against the other hand, a second 
sensation of shock, and then returns to its first position, giving a 



Symptomatology of Pregnancy. 131 

third shock — treble sensation (of departure, of shock, and of return). 
Such are the varieties of balottement, I add abdominal, for we will 
see later that there exists a vaginal. 

Balottement constitutes a positive sign of pregnancy, on one con- 
dition, which is that the tumor giving this sensation must be intra- 
uterine. This condition is, in fact, indispensable, for it sometimes 
happens that abdominal tumors may float in an ascitic fluid. I 
have met two cases of abdominal tumors producing ballottement, 
but these tumors are never intra-uterine. Every intra-uterine tumor 
which imparts the sensation of ballottement, indicates, then, with 
certainty, the presence of a foetus. 

2. Active movements. — By applying the hands for some time on 
the abdominal wall there are felt slight shocks produced by the feet 
of the foetus uplifting the utero- abdominal wall, more rarely by other 
foetal parts. These movements are often perceptible to vision. 
Besides these slight shocks the hand sometimes perceives a more 
extended movement, caused by the displacement of the foetus as a 
whole. These movements, easily perceptible to the mother, are 
often a cause of error on her part on account of the possible con- 
fusion with other analogous sensations ; but it is not the same when 
they are perceptible to the physician. A shock clearly perceived 
by the obstetrician at the surface of a tumor of the abdomen, with- 
out the interposition of the intestine between this tumor and the 
abdominal wall, indicates the positive presence of a living foetus. 

Active movements, perceived by the obstetrician, are, then, a 
positive sign, but on condition of the absence of the intestine, for 
contractions of this organ may sometimes simulate foetal move- 
ments. Now, percussion easily detects the presence of the intestine 
by its sonorousness. Muscular contractions of the abdomen can 
not simulate foetal movements, for the surface of their production 
is too large. I add in conclusion that these active movements tO' 
constitute a positive sign must be clearly perceived. Having 
studied the active and passive movements of the foetus, let us pass 
in review the details of the peculiarities of foetal palpation. 

The head is distinguished by its hardness, its rounded form and 
its mobility, in the absence of engagement in the pelvis. The last 
character is absent when the head is fixed in the pelvic ring, but 
the other characters are sufficient then for its recognition. In case 
of doubt, the groove constituted by the neck will be a valuable 
mark to distinguish the head from the breech. 

The breech is regular at one side (buttocks), irregular at the other 
(pelvic members). It appears larger than the head, when it is 
complete (thighs flexed and close to the body), less in size, on the 
contrary, when it is incomplete. Exceptionally it furnishes the 
sensation of ballottement. 



132 Symptomatology of Pregnancy. 

The thorax and the abdomen are not more often accessible than 
the back of the foetus, and are simply revealed by a certain resist- 
ance to the exploring hand. Sometimes the crest of the spinous 
apophyses can be felt. The shoulder will be recognized by the pro- 
jection it forms in the vicinity of the cephalic extremity. 

With regard to the pelvic or thoracic limbs, outside of the active 
movements by which they are so frequently manifested, they appear 
in the form of a tumor, cylindrical or rounded, easily displaced. 



Epigastrium. 



Hypochondrium. 




Iliac fossa. 



Hypogasirium, 



Fig. 163. — Schematic division of the uterus into different regions. 

With this knowledge of each foetal part, we can begin the study of 
the diagnosis of the presentations and positions by the aid of pal- 
pation. The first foetal part that should be sought, on account of 
the clearness of the sensations which it furnishes, is the head. 
When the situation of the head can be exactly stated, foetal pal- 
pation is three-quarters completed. Let us then take up the 
search for the cephalic ovoid. Fig. 163 shows the different regions 
of the uterus, each corresponding to an analogous region of the 
abdomen. Besides the umbilicus, which is the central and median 
region, the head may occupy : 

1. The hypogastrium. 

2. The iliac fossa (right or left). 

3. The flank (right or left). 

4. The hypochondrium (right or left). 

5. The epigastrium. 

1. The head in the hypogastrium {mobile or engaged) . — This situation 
is much the most frequent, for the hypogastrium leads to the partu- 
rient canal and vertex presentations are the rule. The head, at the 



Symptomatolojy of Pregnancy . 



133 



hypogastrium, may be found in two very different conditions, mobile 
above the superior strait, or fixed in the parturient canal. 

When the head is mobile at the level of the superior strait, more 
or less approached to it, presentation exists, for the foetal part is 
at the entrance to the genital canal, but it may be easily modified, 
either spontaneously or artificially. When, on the contrary^ the 
head has penetrated into the pelvis, the presentation, without be- 
coming absolutely definite, takes a stability, much more marked. 
Mobile at the superior strait, the head may engage by the vertex, 
face or brow. Thus it is impossble to exactly state in advance 
which one of these presentations wdll become definitive at the moment 
of engagement. The obstetrician must then be contented to say in 
such cases, presentation of the cephalic ovoid. But wdien the head 
has penetrated into the excavation, mutations of presentations are 
rare, so that at this moment, save some restrictions, an exact diag- 
nosis becomes possible. 




Fig, 164. — Search for the head in the hypogastrium. 

Let US examine these different cases. To seek the head in the 
hypogastrium, the hands are applied as in Fig. 164. At about five 
centimetres above the superior strait, one seeks, by approaching 
the extremities of the fingers of the two hands, to grasp the body 
which may be interposed between them. If the head is found at 
this level its characters are revealed and it will be more or less 



134 



Symptomatology of Pregnancy. 



mobile. If the head is not met in this first exploration the extrem- 
ities of the fingers are depressed a little ; the superior strait is then 
sought and, at need, even the excavation. If the head is at this 
level we find : A. Presentation of the vertex. B. Presentation of 
the brow. C. Presentation of the face. (The last two exist at the 
moment of labor). 




Fig. 165, — Search for the engaged head in presentation of the vertex (Pinard). 

A. Presentation of the vertex, — On one side the hand finds with 
difficulty the resisting plane furnished by the head ; on the other it 
is quickly arrested by a projecting tumor, clearly appreciable (Fig. 
165). The part of the head difficult to find is the occiput, the other 
projecting, easily explored, is the forehead. According as the pro- 
jection is more or less marked, the exploring hand will note whether 
the forehead is turned posteriorly, transversely or anteriorly. 
This simple exploration, made with precision, permits the recog- 
nition of both the presentation and the position. Exploration of the 
trunk, which will be explained later, will complete this diagnosis. 

B. Brow presentation, — On one side is a voluminous tumor, more 
projecting than the forehead in vertex presentation and here con- 
stituted by the occiput (Fig. 166). On the other side is an unequal 
tumor giving sensation of an incomplete clearness. This is the in- 
ferior part of the face and neck. 

C. Face p)resentation, — On one side is a projection, relatively 
large, seemingly constituting by itself all the foetal head ; this is 



Symptomatology of Pregnancy. 



135 



the occipito-parietal projection, the same as found in brow presen- 
tations but exaggerated by the extension of the head (Fig. 167). 




Fig. 1 66. — Brow presentation with head engaged. 




Fig. 167. — Face presentation with head slightly engaged. 



136 



Symptoynatology of Pregnancy. 



This projection is separated from the trunk by a very clear de- 
pression. On the opposed side the face is explored with difficulty, 
though in cases of mento- anterior the inferior maxillary constitutes 
at this point a sort of horseshoe. 

If we compare the three presentations of the cephalic ovoid, we 
see that palpation of the head gives a projection much more 
marked on one side than on the other. 

Projecting side of the head. — 

Vertex.— Frontal region.— Marked projection. 
Brow. — Occipital region. — More marked projection. 
Face.— Occipito-parietal region.— Very large projection. 

Retreating side of the head. — 

Vertex. — Occipital region. — Smooth. 

Brow. — Face and neck. — Uneven. 

Face.— Contour of inferior maxillary. — Uneven. 




Fig. 1 68. — Thorax presentation; variety; left shoulder. 

In proportion as the head descends into the parturient canal, ex- 
ploration becomes more difficult. Finahy, at a given moment 
during labor, the head becomes no longer accessible to palpation. 

After having recognized and determined the situation of the 
head, it is necessary to explore the breech and the back to complete 
the palpation. The breech is found in one or the other hypo- 
chondrium, in general in that which corresponds to the brow (with 
vertex presentation), rarely on the median line at the epigastrium. 
The back, according as we have to do with a vertex, a brow, or a face 
presentation, will be found more or less approached to the uterine 



Symptomatology of Pregnancy. 



137 



wall. Palpation of the shoulder may aid in completing a doubtful 
or difficult diagnosis in some cases. 




Fig. 169. — Presentation nul (breech and head in the flanks). 




Fig. 170. — Abdomen presentation (breech in the iliac fossa and head in the flank). 

2, TJie head in the iliac fossa {right or left) . — The head is recognized 
by its usual characteristics. The breech is generally situated in 
the flank or in the hypochondrium of the opposite side. According 
to the situation of the back, that is to say of the vertebral column, 
we have, when it looks forward or backward, presentation of the 
thorax, shoulder variety, right or left (Fig. 168) ; when it looks 



138 Symi)iomatology of Pregnancy. 

upward or doTNTiward, presentation of the thorax, sternal or dorsal 
variety. The diagnosis of the presentation will, in general, he 
possible by palpation, from the exact determination of the head 
and that of the back. Back to the front, smooth plane. Back to 
the rear, small parts of the foetus. Where this last point is diffi- 
cult to elucidate in a clear manner, we may arrive by palpation at 
an exact statement of the presentation without being able to affirm 
the variety. 

3. The head in the flank {right or left). — When the head is in one of 
the flanks, it can be recognized by palpation from its usual char- 
acters. The breech is found in the opposite flank or in the 
neighboring iliac fossa. 

In the first case there is no presentation, for the trunk is distant 
from the opening of the genital canal (Fig. 169). To constitute a 
presentation a very marked flexion of the foetus would be necessary, 
so that the child will lie in the inferior segment of the uterus, as in 
a hammock. Then we would have a presentation of the abdomen 
(Fig. 170). 

In the second case (Fig. 171), the breech being in the iliac fossa, 
if its position is maintained at the moment of labor, we would also 
have, and more markedly than above, a presentation of the ab- 
domen. But at this moment the breech generally descends into 
the superior strait, then into the excavation, and presentation of 
the breech is thus constituted in place of that of the abdomen. 

4. The head is in the hypochondrium {right or left) or in the epi- 
gastrium. — When the head is at the fundus of the uterus, either at 
the epigastrium or in one or the other hypogastrium, the breech is 
found at the entrance to the parturient canal, that is, there exists 
a presentation of the breech. 

The head most often occupies the hypochondrium toward which 
Is turned the anterior plane, or the sternum of the foetus, the same 
as the breech in presentations of the vertex. 

The complete breech does not engage in the excavation during 
pregnancy. This is not so with regard to the breech in the incom- 
plete variety of the buttocks, that is found below the superior 
strait during the ninth month, and might be mistaken for the 
vertex in a rapid examination. 

Palpation, of the head in the fundus of the uterus, of the breech 
in the hypogastrium or engaged in the excavation, and finally, of 
the back, placed to the right or to the left, permits us to state 
exactly the foetal situation, and to determine the presentation as 
well as the position. 

By palpation we can also recognize whether the breech is com- 
plete or incomplete variety, the volume of the foetal part being more 
considerable in the first case, and the feet being sometimes per- 
ceptible in the vicinity of the head in the second. 



Symptomatology of Pregnancy. 



139 



Palpation also affords exact information on the diagnosis of twin 
pregnancies, on the death of the foetus, and as to different patho- 
logical states. 

Some words on the difficulties of palpation and we shall have 
finished with this method of exploration. These difficulties may 
be met at each one of the three portions that have been discussed. 




Fig. 171. — Complete breech presentation RSI A. 

1. Prceuterine. — Fatty infiltration of the abdominal wall makes 
the sensation obscure in obese women. Exaggerated sensitiveness 
of the abdominal wall may obstruct palpation to such a point that 
in cases where precision of diagnosis is indispensable it is neces- 
sary to have recourse to anaesthesia. Uterine anteversion may 
render foetal palpation very difficult. In this case the fundus of 
the uterus must be pushed as far backward as possible. 

2. Uterine. — Tumors of the uterine Avail (multiple fibroids), 
rigidity of this wall in primiparae, or in hydramnios of twin preg- 
nancy, obstruct the hand in exploration of the foetus. This may 
also occur from too frequent contractions of the uterus during 
pregnancy and especially during labor. 

3. Intra-uterine, — An excess of the amniotic liquid, twin pregnancy 
and death of the foetus are causes of difficulty that experience 
alone can surmount. 

4. Auscultation. — From experience it has been learned that 
by applying the ear to the abdominal wall of a woman toward the 
term of pregnancy, there can be heard four varieties ofsounds : 



140 



Symptomatology of Pregiiancy. 



A. A maternal souffle, - - - Mother. 

B. A foetal double pulsation, - . j 

C. Foeto-funicular souffle, - - v Foetus. 

D. Sounds of foetal movements, - - ) 

Before beginning the study of these sounds, some preliminary 
words on the mode of practicing obstetrical auscultation will be 
useful. 

Preliminaries. — The woman should be placed in the same position 
as for palpation (or .better left in this position), since digital ex- 
ploration and auscultation generally follow palpation. The ac- 
coucheur remains likewise on the right side of the woman, but may 
change sides to complete his examination. 

Auscultation is either immediate or mediate : Immediate, when 
the ear is directly (or better, with the linen or the chemise inter- 
vening) applied to the abdomen. Mediate, when a stethoscope is 
interposed between the ear and the abdomen. This last method is 
generally preferred, as less offensive to the woman's modesty and 
as furnishing clearer and more exact results. 





Figs. 174, 175. — Bell of obstetrical stethoscope. 

The choice of a stethoscope is not a matter of indifference ; those 
employed for the thorax are not so favorable for obstetrical auscul- 
tation. The essential condition of a good obstetrical stethoscope is 
that it shall have a large bell, for example, like that represented in 
Figs. 174 and 175. With these preliminaries we may proceed to 
the study of the different puerperal sounds. 



A. Maternal souffle, — The maternal souffle presents several im- 
portant characteristics : 

It is intermittent and synchronous with the pulse of the woman. 
If the uterus is auscultated at the same time that the finger explores 
the radial artery, at the moment the pulse is felt at the wrist the 



Symptomatology of Pregnancy. 141 

ear hears a sound which occupies a duration of one-quarter, one- 
third, or one-half of a cardiac revolution. 

Uterine Contraction. 



Maternal 
Souffle. 




I 
Fig. 176. — Evolution of the maternal souffle during uterine contraction. 

Its timbre is variable ; sometimes acute, sometimes grave, some- 
times musical. It may be situated at any point of the uterine sur- 
face, but is heard most often over the sides, or at the border of the 
insertion of the broad ligaments. Its site is sometimes single, 
sometimes double, sometimes multiple. When following uterine 
contraction, it undergoes an augmentation of intensity, then sinks 
below normal, to resume its first intensity when the contraction is 
ended. These variations are put in schema form in Fig. 176. 

This souffle appears generally at the beginning of the second 
three months of pregnancy, augments up to the commencement of 
the third three months, when it attains its apogee, and decreases 
from this time (Fig. 177). 

1. Aorto-iliac theory (Hans, Bouillard). — The souffle is pro- 
duced in the aorta and in the iliacs compressed by the uterus. If 
this were so it would be impossible to find the souffle at any point 
of the uterine surface, notably above the pubis where it is often met. 

2. Epigastric theory (Kiovisch, Glenard). — These two authors 
have localized the maternal souffle in the epigastric arteries. 

The objection made to the preceding theory applies equally to 
this and demonstrates its untruth. Glenard has, besides, abandoned 
his theory, placing in the puerperal artery that which had formerly 
been attributed to the epigastric ; the puerperal artery being a de- 
pendent of the uterus, this author is thus ranged in the uterine 
theory, which will be exposed later. 

3. Placental theory (Laennec, Monod). — The possibility of having 
two or three distinct spots where the maternal souffle can be heard 
invalidates this theory. 

4. Uterine theory (P. Dubois). — This is the generally admitted 
theory, localizing in the vessels of the uterus the origin of the ma- 
ternal bruit or souffle; thus it is often called the uterine souffle. 
But, though in accord on the principle, authors differ as to what 
variety of vessels is involved. The schema Fig. 179 represents the 
succession of uterine vessels showing the divisions, and the authors 
cited have been placed opposite the variety of bloodvessels ad- 
vanced as a cause. 



142 



Symptomatology of Pregnancy. 



A physical law proves that a sonorous sound is produced when a 
fluid circulating in a tube passes from a narrow region into an en- 
largement ; this law demonstrates that P. Dubois is correct in sup- 
posing that the maternal souffle arises at a moment when the blood 
empties from the capillaries into the sinuses. Besides, it is not 
impossible that the other uterine vessels compressed accidentally 
by the stethoscope, by a tumor, by a foetal part, or by any analo- 
gous cause, may be equally the source of a maternal bruit. 

The maternal souffle, then, takes origin in any point of the uterine 
bloodvessels, hut preferably at the union of the capillaries with the 
sinuses. 




:nojS 



t/i 



Dt/\flV370 






o 



^\\si09nQy jr! 



T3 
C 
O 



71JV3DI\j I 






73 



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B. A foetal double pulsation. — When practicing auscultation of the 
foetal heart, the sounds of which have been compared to the remote 
ticking of a watch, there is heard (Fig. 180) : 

1. A first sound, tolerably strong. 

2. A short silence. 



Syjnptomatology of Pregyiancy. 143 

3. A second sound, more dull. 

4. A long silence. 

The foetal heart beats on the average one hundred and forty times 
a minute ; one will hear, the double sound in question one hundred 
and forty times a minute. The number of pulsations being about 
seventy in the adult, it will be seen that thej are double this 
number in the foetus. 

Fig i8o.— Foetal heart sounds. 

The number of foetal pulsations may present quite extensive 
variations : 

_,,.,.,,. .^ f Maximum, l6o. 
Physiological limits {Minimum, I2C. 

p , , . - ,. . f Progressive diminution, loo, 90, 60, etc., to foetal death, 

ratnological limits -j^ Augmentation to 190, 200, in cases of intense fever of the mother. 

Uterine contraction 



Foetal heart 
sounds. 



/ 



Fig. 181. — Evolution of foetal heart sounds during uterine contraction. 

During uterine contraction, the frequency is exaggerated moment- 
arily at the beginning, then diminishes sometimes to such a degree 
that the ear perceives no sound. The obstetrician should not forget 
this peculiarity, which may lead to a belief that the condition of the 
foetus is serious, when there is only a passing modification. Fig. 

181, in schematizing the variations of the foetal heart sounds during 
uterine contraction, shows the analogy with that taking place in the 
maternal bruit. 

During the first three months of pregnancy, it has never been 
possible to hear the foetal heart sounds. Exceptionally they can 
be perceived during the fourth month, but more often during the 
first half of the fifth month ; it is in general, however, at about the 
middle of pregnancy that they become distinctly perceptible ; their 
clearness progresses to the end of gestation as in the schema, Fig. 

182, which sums up what we have said. 

The perception of the the foetal heart sounds permits us to affirm 
the existence of pregnancy and that the foetus lives. However, this 
sign may be attached to certain causes of error ; thus the maternal 
cardiac pulsation transmitted to the abdomen may be mistaken for 



144 



Symptomatology of Pregnancy. 



the foetal heart sounds. To avoid this confusion it is sufficient to 
explore the maternal pulse while auscultating the mother ; the syn- 
chronism indicates the maternal origin of the sounds. From this 
comes the very important precept: Never auscultate the foetus 
without taking the maternal pulse at the same time. In difficult 
cases, the obstetrician who fears a confusion with the throb of his 
own arteries (arteries of the head, in particular the temporal) will 
avoid all source of error by taking his own pulse simultaneously. 




7Z 



These causes of error, it is seen, are very easy to avoid, and hence 
the exellence of the foetal heart sounds as a positive sign of preg- 
nancy. The perception of these sounds permits, besides, a watch 
over the life of the foetus, and during labor furnishes the physician 
important knowledge as to the necessity of prompt intervention 
when a life is in danger. 

It has been pretended also that by the aid of auscultation one 
could recognize during pregnancy the sex of the foetus. In 1859 
Frankenhauser advanced the following relation: More than one 



Symptomatology of Pregnancy. 145 

hundred and forty-four pulsations to the minute, a girl; less 
than one hundred and forty- four pulsations, a boy. Taking up 
this question again in 1879 Danzats modified the preceding con- 
clusion. More than one hundred and forty-four pulsations to the 
minute, a girl; less than one hundred and thirty-five, a boy. Dan- 
zats created thus between one hundred and forty-four and one hun- 
dred and thirty-five pulsations a neutral zone where diagnosis was 
impossible. From the researches of Budin and Chaignot, made 
the same year, it resulted that these figures had no utility in 
practice, and that it is necessary to renounce all ideas of diagnosti- 
cating the sex of the child during pregnancy by auscultation or by 
any of the other means proposed to this end. 

Finally, foetal auscultation permits us to verify the diagnosis of 
the presentation and j^osition made by palpation, and this study will 
terminate the subject of foetal heart sounds. The sounds of the 
foetal heart are heard within a zone more or less extended on the 
abdominal wall, a zone which represents a circle of ten to fifteen 
centimetres diameter. In proportion as the ear or stethoscope is 
approached to the center of this circle, the sound becomes clearer 
and stronger. This region, where the heart sounds are particularly 
clear, is called the focus of auscultation. This focus is usually single ; 
however, as will be seen later in a simple pregnancy, it may be 
double, as in the case of twins. The foci of auscultation will vary 
with the situation of the foetal heart ; that is, each presentation and 
position will have its special focus. Let us study these different 
foci by commencing with the presentation of the cephalic ovoid. 

1. Vertex. — I will suppose the vertex engaged in the excavation 
(we will see later that the height of the focus of auscultation varies 
with the degree of engagement). I use as a diagram a series of 
lines which take the umbilicus as a starting point and dispose 
themselves in a fan shape to the different points of the pelvis, as 
follows (id. both sides) : 

Antero-superior iliac spine. Superior ilio-umbilical line. 
Antero-inferior iliac spine. Inferior ilio-umbilical line. 

Ilio-pectineal eminence. Umbilico-pectineal line. 

Pubic spine. Umbilico-pubic line. 

Total : eight lines. 

It is on the paths of these eight lines that we find the foci of 
auscultation of the eight positions of the vertex. 

Schema 183 represents the site of the different foci of auscultation 
at the point where each one interrupts a line ; the name of the 
position is given at the side. 

It will be remarked that for LOP there exists two foci. This is 
the only position where this peculiarity exists. The line on which 
is seated the left focus is found above the left superior ilio-umbilical 
(supplementary line). In proportion as the back of the foetus turns 



146 



Symptomatology of Pregnancy, 



posteriorly the right focus becomes more and more clear, and, on 
the contrary, it is that of the left that becomes louder when the 
back is directed forward, approaching LOT. 

To reconstruct this schema from memory it is sufficient to recall that 
the focus of L O A (the line of which is expressly accentuated) is 
found on the left inferior ilio-umhilical line. 




Fig. 183. — Vertex. Foci of Auscultation. Stethoscopic Fan. 



Foetal Part 

SuPEfi!DF Strait 

2 

Ex C A VAT 1 IM 

Meo/w a/. Stfi\ it 

VuL+t++HmmitvA 






Fig. 184. — Height of foci of Ausculation varying according to the degree of 
engagement of the foetal part. (The inferior lines indicate the height of the foetal 
part which presents and the superior analogous lines the height of the foci of auscul- 
tation which corresponds to them.) 

What has been said applies to cases where the vertex is engaged 
in the excavation. But what is the site of the different foci when 
engagement has not taken place or when, on the contrary, the head 



Symptomatology of Pregnancy. 



147 



has arrived at the vulva ? Fig. 18 1 responds to this question ; it is 
destined to show the relative height of the foci of auscultation, fol- 
lowing the degree of engagement of the foetal part ; the upper black 
line corresponds to the foetal part free. 

These different heights being known it is sufficient to return to 
Fig. 183 and transport, parallel to itself, each of the foci, either up- 
ward or downward, according to the degree of engagement; thus 
we will have the successive positions occupied by the foci during 
the successive descent of the head. 

Examples : In L T, head mobile above the superior strait, the 
focus will be in A. 

In S, head fixed at superior strait, the focus will be in B. 

In P, head at the vulva, the focus will be in C (Fig. 185). 




Fig. 185. — Vertex. Variaiions in the height of fr cus of nuscultation 
according to the degree of engagement of the foetal part. 

2. Face. — I proceed likewise for the determination of the foci in 
the positions of the presentation of the face, supposing that labor 
is advanced so that the foetal part is in the excavation. The stetho- 
scopic fan is given in Fig. 186. The mnemotechnic mark here is 
the L M A line, the same as L A for the vertex. The K M P is 
here analogous to L P as to a double focus, for the cardiac region 
of the foetus is equally distant, right and left, from the abdominal 
wall. x\lthough this double focus has not been described, it is 
probable that it exists and for my part I have been able to recognize 
it in a similar case. With regard to the height of these different 
foci, according to the degree, of engagement, I return to what has 
been said of the vertex. Fig. 184 applies as well to presentations 
of the face as to those of the vertex. 

3. Forehead. — The different foci of auscultation in presentation 
of the forehead are not sufficiently known to allow me to touch 



148 



Symptomatology of Pregnancy. 



upon their description. They demand new study. Each presen- 
tation of the forehead being intermediate between a presentation of 
the vertex and of the face, one can take a point situated on the 
middle of a Hne reuniting the two foci of corresponding presentations 
and approximately fix the site of the one sought. 



.•^!i^ 




Fig. 1 86 — Face. Foci of aubcuitaucn. JStethuscopic fan. 

4. Breech. — I suppose the breech engaged in the excavation, the 
foci are disposed in a fan (Fig. 187) analogous to those of the face 
and vertex. For E S P I have marked two foci of auscultation 
which exist probably as in L P or E M P, but this fact has not 
been verified. The line L S A is that from which the fan can be 
reconstructed from memory. With regard to the height of the foci, 
I will repeat that which has been given for the vertex and face, for 
since the researches of M. Eibemont, it has been shown that in a 
foetus doubled on itself, as it is in the uterine cavity, the heart is 
equally distant from the vertex and from the breech; the height cf 
the focus of auscultation will be the same for the vertex and for the 
breech with equal degrees of engagement. Presentation of the 
breech being very rarely accompanied by engagement during preg- 
nancy, it will be understood that the foci of auscultation will be 
found in parallel circumstances above the umbilicus. 

5. Thorax. — Shoulder presentations, other than the varieties of 
the right or left shoulder, being rare, we have only at present de- 
termined the foci for these two varieties, and in their two most 
usual positions, that is, the right and the left acromio-iliac trans- 
verse, EAT and LA T. 

6. Abdomen. — The great rarity of these presentations has not yet 
permitted us to determine the foci of auscultation. 

Besides the engagement of the foetal part, there are other causes 
which may produce variation in the situation of the foci of auscul- 
tation, such as lateral inclination of the uterus, or, again, anterior 



Symptomatology of Pregnancy. 



149 



inclination, which, for example, notably lowers the focus in L T, 
w4ien it is pronounced. All these variations are complications, but 
the physician should never forget their possibility, in order to keep 
in mind certain apparent anomalies, the details of which are too 
extended to produce here. The knowledge of the preceding foci as 
described is not sufficient alone for diagnosis of presentation and 
position, but it permits us, diagnosis being first made by palpation, 
to obtain verifications by the aid of the ear, and enables the 
assurance that the focus is placed in the situation indicated for the 
supposed presentation and position. A focus placed in another 
region puts one on the track of an error committed and leads to the 
necessary rectification. 



<^^'^/: 




rNvn 



Fig. 187. — Breech. Foci of auscultation. Stethoscopic fen. 

C. Foeto-ftcnicular souffle. — At the same time with the foetal heart 
sounds, there is sometimes heard a blowing sound, usually single, 
exceptionally double. This souffle differs essentially from that 
previously studied (maternal souffle), and is easily distinguished 
from it, for the first is synchronous with the pulsations of the 
mother, the second, with the foetal pulsations. 

The foeto-funicular souffle recognizes, as its name indicates, a 
double origin : Either the foetus, cardiac (heart) souffle ; or the 
cord, funicular (vessels) souffle. The cardiac souffle of the foetus is 
due either to a lesion of the valvular orifices, as in adults ; to an in- 
sufficient permeability of the foramen ovale ; or, with a normal 
heart, to modifications in the blood, producing sounds analogous to 
those which are designated under the name anaemic in the adult, 
and the pathology of which is still unknown. 

The funicular souffle, exceptionally caused by the semilunar folds 
which exist in the umbilical vessels, is generally due to compression 
of the cord, either between the back of the child and the uterine 
wall, or by circular constrictions. Charrier, in making of this 
souffle a sure sign of circular constriction of the cord, has been 



150 Symptomatology of Pregnancy. 

much too positive, and is unwise in proposing premature artificial 
labor in such cases to save the life of the child. 

We do not possess exact and sufficient symptoms to enable us to 
recognize the different varieties of foetal cardiac souffle, so that all 
the ambition of the obstetrician should be confined to distinguishing 
a foetal souffle from a funicular souffle, and yet this diagnosis 
is not always possible. The cardiac souffle has its maximum of 
intensity at the focus of auscultation of the foetal heart, and, on 
the contrary, the funicular souffle has its maximum of intensity 
situated at a different point, in the region of the cord. This sign is 
that which will better permit the differentiation ; those distinctions 
which are based on the intensity or the variability of the murmur 
furnish only an incomplete security. The foeto-funicular souffle 
has, in the point of view of the existence of pregnancy, the same 
semeiological value as the foetal heart sounds — it indicates the 
presence of a living foetus, but its importance is very small com- 
pared with the existence of the foetal heart sounds, so clear and 
easy to find. 

D. Sounds of foetal movements. — In practicing auscultation during 
a certain time there is perceived sometimes a rustling, analogous to 
that produced by the two hands applied on the ear when a slight 
movement is given to the outer one. Sometimes a shock is heard, 
sudden and dull, like that obtained wdien striking with one finger on 
the hand covering as before the pavilion of the ear. Occasionally 
these shocks take a peculiar regularity, as if the foetus pulsated 
slowly in the interior of the ovular cavity {rhythmic movements). The 
rustlings are due to the displacements of the foetus in totality ; the 
shocks, to movements of small foetal parts which strike the uterine 
wall ; the cause of the rhythmic movements is ignored, besides they 
have no special semeiological value. The sounds of foetal movements 
commence with the movements themselves, that is, at the beginning 
of the fourth month of pregnancy, but they are not clearly per- 
ceptible until about the middle of the fourth month. Like the 
foetal heart sounds, they constitute a positive sign of the existence 
and the life of the foetus. However, it is important not to confuse 
them with intestinal sounds, nor with the shocks which abdominal 
muscular contractions may give to the stethoscope. These causes 
of error can only be avoided in the second half of pregnancy, w^hen 
the perception of the foetal shock had become clear and distinct; 
but at this time this symptom, which would be important if unique, 
generally loses its advantages by the appearance of other signs of 
pregnancy more easily appreciated. 

5. Digital examinaiton. — The uterus is directly accessible by 
the vagina, indirectly by the rectum and bladder, in such a w-ay 



Symptomatology of Pregnancy. 



151 



that the finger penetrating into these different cavities may furnish 
valuable information on the gestating organ and its contents. This 
exploration is dependent upon the sense of touch. It is then only a 
variety of palpation. One is internal, the other is external. In 
these internal explorations the fingers are in contact with the 
mucous membrane, in palpation they are in contact with the 
integument. 

Digital examination can be made : 

1. By the urethra and bladder — vesical touch. 

2. By the anus and rectum — rectal touch. 

3. By the vulva and the vagina— vaginal touch. 

I shall be brief as to the first two and shall dwell, on the con- 
trary, on the last. 

1. Vesical touch requires a previous dilatation of the urethra, an 
operation which prevents its use in pregnancy. 

2. Rectal touchy practiced after a previous evacuation of fecal 
materials, gives information on the volume of the uterus, on the 
exact situation of tumors placed behind it and on some other points 
of secondary importance. It should be resorted to when vaginal 
examination is difficult or impossible on account of some obstacle, 
such as vaginismus, retraction or cicatricial obliteration of the 
vagina, intact or too narrow hymen. But the^e conditions are ex- 
ceptions and in the great majority of cases vaginal touch will be 
used. 




Fig i8q — Dorsal position. 

3. Vaginal touch may be performed with the w^oman in the upright 
position or lying down. The upright position permits a rapid and 
summary examination, but very incomplete. The horizontal position 
is the only one which allows a conscientious and satisfactory exami- 
nation and, except in rare cases, it should always be used. 

The w^oman should be placed in the same position as for pal- 
pation, or rather left in this position, since one generally practices 
digital examination after palpation and auscultation, there is simply 
needed a slightly more marked separation of the tliighs (with slight 
flexion and the elevation of the buttocks with the aid of a cushion 
dorsal position) (Fig. 189). Such is the French position. In Eng- 
land the w^oman is placed on the left side, the thighs flexed at a 
right angle on the trunk, the upper one a little more than the 



152 



Symptomatology of Pregnancy, 



lower {lateral position) (Fig. 190). Exceptionally, and in certain 
pathological conditions, the woman is placed on the knees and 
elbows {genu-pectoral x)osition) (Fig. 191). 




Fig. 190. — Lateral position. 

Let us suppose the woman in the dorsal position and proceed to 
digital examination. Exploration may be made with either hand, 
by preference with the right, the most used ; in this case the phy- 
sician places himself at the woman's right. It is important for 
this to place the woman in her bed so that her right side is easily 
accessible. 




Fig. 191. — Genu-pectoral position. 

Digital examination or touch may be : 

Unidigital: practiced with the index finger, the other fingers 
being flexed and folded in the hollow of the hand (Fig. 192). 

Bidigital: index and middle finger (Fig. 193). The introduction 
of two fingers gives greater length, the middle finger permitting 
deeper penetration, and may be used in multiparous women with- 
out inconvenience. In a primiparous women this simultaneous 
introduction is often painful and should be avoided. 

Manual: the whole hand can be made to penetrate into the geni- 
tal organs, usually to explore the contents of the uterus, in case of 
vicious presentation for example. The hand, disposed as in Fig. 
194, can scarcely ever be introduced without anaesthesia. 

While one hand practices vaginal touch, the other should always 



Symptomatology of Pregnancy, 



153 



be placed on the abdomen, combining and completing the explo- 
ration. The finger that is introduced into the genital organs should 
be aseptic and covered with an oily substance to permit an easy 
gliding (vaseline, oil, cold cream, cerate, etc.). 






Fig. 192. — Unidigital touch. FiG. 193. — Bidigital touch. Fig. 194. — Manual touch. 

Vaginal touch is executed, like palpation, by a series of examin- 
ations : 

1. Vulvar. 

2. Vaginal. 

3. Uterine. 

4. Periuterine, 

5. Pelvic. 

The pelvic exploration is only a variety of the periuterine, but I 
separate them for the clearness of description. 

We shall study first digital examination on the non-pregnant 
woman, to note the changes caused progressively by the develop- 
ment of the ovum. 



A. Vaginal touch in the non-pregnant woman. — 1. 

Vulvar. — The vulva being easily accessible to vision, the obstetrician 
will derive more information from exploration of the region by the 
eye than by the finger. There are two orifices that it is necessary 
to become familiar with by touch, the urethral for catheterism and 
the vaginal which conducts the finger toward the cervix. Explo- 
ration is commenced by search for the vaginal orifice. For this the 
finger will be held vertically, direct along the inner surface of the 



154 Symptomatology of Pregnancy. 

thigh, until in contact with the vulvo-perin?eal region where the 
vulvar opening is detected. At this moment the finger is generally 
in contact with the perinaeum and by ascending a little the vaginal 
orifice is reached. To determine the situation of the urethral 
orifice, the finger, after having found the vaginal orifice, explores 
the vestibule from below upward and meets a small opening, which 
with a little experience can be easily recognized. 

2. Vaginal. — The finger in passing through the vagina passes 
successively the vulvo-vaginal orifice and the muscular ring con- 
stituted by the coccy-perinaeal levator. Continuing on its way the 
finger following, sometimes the anterior wall, sometimes the pos- 
terior wall, sometimes the right or left lateral wall, arrives in the 
corresponding culs-de-sac which surround the cervix. I only note 
in passing the importance of seeking carefully for double vaginas, 
which often pass unnoticed. 

3. Uterine. — To attain the cervix in difficult cases, it is necessary, 
the buttocks of the patient being elevated : 

a. To depress the elbow to the plane of the bed, thus giving the 
finger a proper direction. 

h. To separate successively the labia majora and minora of each 
side, in such a way as to insinuate the hand between them ; by this 
manoeuvre one can easily penetrate a finger's breadth farther. 

When the cervix is examined, the anterior, lateral and posterior 
surface of the uterus can be explored, by successively depressing 
each cul-de-sac, while the abdominal hand affords a support from 
above downward in an umbilico-coccygeal direction. 

4. Periuterine. — By depressing the vaginal wall, circularly from 
the posterior to the anterior cul-de-sac, the finger meets : 

The rectum. 

The ovary "j 

The tube >- Broad ligament. 

The round ligament J 

The bladder, ureter, urethra. 

The exploration of the ovary, of the tube, and especially of the 
round ligament and the ureter demands great experience, and some- 
times the most experienced finger can not perceive them. The 
direction in which the finger leaving the uterus will meet the dif- 
ferent organs is indicated by Fig. 195. These different organs are 
more easily found when they become the seat of a pathological 
change and it is also in such circumstances that their exploration 
becomes useful. 

5. Pelvic. — By strongly depressing the vagina and the contiguous 
soft tissues, one can, without actual pain to the woman, explore the 
pelvic wall and even arrive at the superior strait and at the sacro- 
vertebral angle. The great importance of this examination will be 
comprehended in the study of the pathological pelvis. 



Symptom atolooy of Pregnancy. 



155 



Bladder and urethra. 




^ Round ligamem. 



-Tube. 



"^ Ovary. 

'^ ^ Rectum, 
Fig. 195. — Periuterine touch. 

B. Vaginal touch during pregnancy. — We shall follow the 
different steps indicated above, noting the modifications caused by 
conception. 

1. Vulvular. — There is no important change outside the hypertro- 
phy of its elements. 

2. Vaginal. — I simply recall the circular fold which is sometimes 
formed at an advanced period of pregnancy. The finger often 
finds small projections in the vaginal wall, a little larger than the 
head of a pin. These are the result of granular vaginitis, a frequent 
affection of pregnancy, manifested as a blennorrhagic vagmitis by a 
yellowish leucorrhoea, but absolutely distinct with regard to its 
nature and it is not venereal, although it relates to microbes. 

3 Uterine. — At an advanced period of pregnancy, when the cervix 
is completely softened and its consistency identical with that of the 
vagina, even a practiced finger may meet actual difficulty in cervical 
exploration. To find the cervix in difficult cases it is necessary to 
follow the vaginal fundus in different directions ; in this series of 
successive explorations the finger will meet the organ and recognize 
its orifice. 

The finger permits us to verify the modifications of the cervix and 
of the body of the uterus (hypertrophy and softening). The soften- 
ing of the cervix and the augmentation of the volume of the body 
of the uterus are, at the beginning of pregnancy in the absence of 
positive symptoms which do not exist at this period, valuable 
indices for diagnosis. 

Toward the middle of pregnancy appears the ballottement, called 
vaginal in distinction from abdominal. When the finger placed in 
the cervix, or in one of the culs-de-sac (preferably in the anterior), 
impresses a slight push from below upward, it has the sensation of 



156 Symptomatology of Pregnancy. 

a hard body which retreats and, at the end of some seconds, strikes 
upon the finger in resuming its first position. This sensation of 
retreat and return is balottement. It is generally produced by the 
head of the foetus, exceptionally by the breech, sometimes by 
another foetal part. Very exceptionally ballottement may be per- 
ceived at the beginning of the second three months of pregnancy. 
In general it is only felt after four months and a half, and it 
becomes especially clear during the seventh month; during the 
ninth month it is met no longer unless there is hydramnios, for the 
foetus becomes too heavy and too closely surrounded to retreat 
before the pressure of the finger (Fig. 196). 

Vaginal ballottement. 




1 2 

Nul. • • • 



Fig. 196. — Vaginal ballottement. 

Is vaginal ballottement a positive sign of pregnancy ? An analo- 
gous ballottement may be produced by a large vesical calculus, or 
by the body of the uterus in anteflection and very mobile on the 
cervix, or again by some periuterine tumor. Like all other positive 
signs, vaginal ballottement has then its sources of error, but these 
are avoided if, as in abdominal, all ballottement is eliminated that 
is not produced by an intra-uterine tumor. Vaginal ballottement 
produced by an intra-uterine body is, then, a positive sign of 
pregnancy. By this restriction the above-mentioned sources of 
error will be avoided, i. e., those belonging to periuterine or uterine 
tumors, for none of them are intra-uterine. 

But it is asked. How may we be assured that the tumor is intra- 
uterine ? This is decided by attentive exploration of the inferior 
segment of the uteras, and in doubtful cases, by waiting a con- 
traction by which we may be assured that the tumor explored is 
contained in the uterus. There may be doubtful cases where the 
obstetrician may be unable to decide, but this is no reason for 
eliminating ballottement from the positive signs, for with such 
reasoning there would remain no positive signs, not even the sounds 
of the foetal heart, which are sometimes too vague to be affirmative. 

Digital examination also permits, at a sufficiently advanced period 
of pregnancy, recognition of the characters of the foetal part which 
presents. When this relates to the vertex there is a smooth, even, 
hard tumor, usually engaged in the excavation. When there is 
presentation of the brow, the tumor is also smooth but not engaged. 
In a face presentation, the tumor is somewhat unequal, with a 



Symptomatology of Pregnancy. 157 

smooth forehead and regular at the side. There is no engagement 
(very exceptional during pregnancy). The breech is recognized by 
tumor, less hard than the head and less equal, accompanied by 
small parts and not engaged when the breech is complete, often 
engaged on the contrary, when it is incomplete. With a presen- 
tation of the thorax or abdomen the foetal part is usually inaccessible 
during pregnancy. 

In many cases the details of the foetal presentation can be felt 
through the uterine segment and to this I shall return apropos of 
examination during labor, when the cervix is open. In some cases 
of great permability of the cervix, the exploring finger arrives at a 
foetal part simply covered by the membranes, and clearly recognizes 
the presence of a child by noting a hand, a foot, an osseous suture, 
a fontanelle or the ocular globe. The clear perception of a foetal 
part by vaginal touch is a positive sign of pregnancy, but it is of 
service only in relatively rare cases. 

4, 5. Permterine and pelvic. — The bladder and the uterus may also 
be explored by the finger during pregnancy, although the bladder 
often ascends above the pubes. With regard to the broad liga- 
ments and the organs they contain, their ascension with the uterus 
renders them inaccessible to vaginal examination. I only mention 
the examination of the pelvis, in which pregnancy causes no modi- 
fication perceptible to touch in the normal state. (The pathological 
modifications will be stated under puerperal pathology.) 



158 The Diagnosis oj Pregnancy. 



CHAPTER VII. 



THE DIAGNOSIS OF PREGNANCY. 

Tlie various signs of 'pregnancy wliich we shall now study in detail 
are divided into two categoiies : 

1. The first, dependent on the mother, are called probable or pre- 
sumptive signs, for if they afford a suspicion of pregnancy and 
render it probable, they do not authorize its affirmation. 

2. The second, dependent on the foetus, are termed positive signs, 
for their presence places pregnancy beyond doubt. 

I shall only recall these various signs, as we are now familiar with 
them and as their value has been discussed in describing them. 

A. Probable or maternal signs. 

1. Genital system and vicinity. 

Uterus. — Suppression of the menses. 

Progressive increase in size. 

Special softness of the body and of the cervix. 

Intermittent contractions. 

Existence of the maternal souffle. 
Vagina. — 'Vaginal pulse. 

Violaceous coloration. 
Vulva. — Hypertrophy. 

Violaceous coloration. 
Abdominal wall. — Increase in size of the abdomen. 

Linaer albicantes. 

Pigmentation along the line a alba. 

Umbilicus : Depression, then flattening, sometimes 
projections. 
Breasts. — Increase in size. 

Projection and exaggerated sensitiveness of nipples. 

Flow of colostrum. 

Hypertrophy of Montgomery's tubercules. 

Pigmentation of the areolae, and formation of the 
secondary areola. 

Linese albicantes. 

2. Nervous sy stern. 

Modifications of the senses of the intellect and of 
the will (abnormal desires). 

3. Respiratory system. 

Dyspncea. 

Modification of the quantity of carbonic acid exhaled. 



The Diagnosis of Pregnancy. 159 

4. Circulatory system. 

Globular anaemia and serous plethora. 

Cardiac hypertrophy. 

Peripheral venous dilatation (varices). 

5. Urinary system. 

Diminution of the solid elements of the urine. 
Frequency of albuminuria and of glycosuria. 
Frequency of disturbances of micturition. 

6. Cutaneous system. 

Pigmentary collections. 

7. Digestive system. 

Modifications of the appetite. 

Vomiting. 

Eetardation of the different nutritive processes ; ab- 
sorption, assimilation, disassimilation, elimi- 
nation, with different diseases resulting. 

B. Positive or foetal signs (Six). 
Tivo obtained by palpation. 

1. Passive movements or abdominal ballottement. 

2. Active movements. 
Two by auscultation. 

3. Foetal heart sounds (or foeto-funicular souffle). 

4. Foetal movements. 
Two by digital examination. 

5. Passive movements or vaginal ballottement. 

6. Detection of a foetal part. 

I recall that these positive signs to be actually considered as such 
must unite certain indispensable conditions, which are : 

1. Clearness. — When our sensations are not sufficiently exact, con- 
clusions should be suspended. 

2. Certain peculiarities. 

a. For abdominal ballottement. — The tumor which gives the sen- 
sation of ballottement must be intra- uterine. 

b. For the active movement pterceived by palpation. — There must be 
no interposition of intestine between the uterus and the abdominal 
wall. 

c. For the foetal heart sounds. — There must be no synchronism with 
the maternal pulse 

d» For audition of the foetal movements. — The woman must be 
absolutely quiet and contract no muscle of the abdoniinal wall. 

e. For vaginal ballottement. — The tumor affording ballottement 
must be intra-uterine. 

/. For detection of a foetal part. — The foetal part explored must 
exactly recall a region of the child easily appreciated. 



160 The Diagnosis of Pregnancy. 

With these signs in view let us examine the possibilities of the 
diagnosis of pregnancy at different periods in its development. I 
shall especially have in mind normal (physiological) pregnancy, and 
shall close with some considerations on the difficulties that different 
pathological states may surround the diagnosis 

A. Normal pregnancy. — Pregnancy lasts nine months, which 
may be divided into three parts, and the diagnosis varies according 
as we have to consider the first, the second, or the third three 
months. , 

First three months. — During this time no positive sign appears 
and we are then forced to hold to probable signs. Among these 
there are three especially which should, on account of their relative 
importance, fix the attention of the obstetrician and which are like 
a diagnostic tripod at this period, the other signs only constituting 
adjuvants. These are : 

1. The modifications of the breasts (development of the gland, of 
the tubercles of Montgomery, pigmentation of the areola, presence 
of colostrum.) 

2. The cessation of the menses. 

3. The increase in volume and the softening of the uterus. 

If we are consulted by a woman: (1) who can afford exact infor- 
mation on the modifications of the breasts ; (2) whose menstruation, 
habitually regular, has been suddenly arrested without appreciable 
pathological cause, and (3) finally, when palpation permits us to 
state clearly the increase in size and the softening of the uterus, 
we can be almost sure of the existence of pregnancy. 

The association of these three signs of probability is almost 
equivalent to a positive sign; I say almost, for the existence of 
pregnancy should never be affirmed before meeting one or more of 
the positive signs. 

The other probable signs may be grouped around the preceding 
three and by their number and clearness may diminish the chances 
of error. But one, or even two, of these three probable signs may 
be more or less absent, obscuring the diagnosis. On the other hand, 
each of these three signs may be the consequence of pathological 
states clearly distinct from pregnancy. I shall only mention these 
different causes of error, not having space for a complete differ- 
ential diagnosis. 

1. Modifications of the breasts {development of the gland, presence 
of the colostrum, and pigmentation and developtment of Montgomery's 
tubercles). — The last two signs are of a very different appreciation. 
It is necessary to have known the areolae, and to have preserved an 
exact memory to appreciate the changes. Simple extemporaneous 
observation cannot be sufficient, except in rare instances. 



The Diagnosis of Pregnancy. 161 

The augmentation of voiume is also produced under the influence 
of adipose deposit, in cases where the simultaneous development of 
the abdomen may also lead to a supposition of pregnancy. 

With regard to the presence of colostrum, it has actual im- 
portance only in the primiparse, for in women who have had 
children, and especially those who have nursed children, there may 
be, for a longtime after weaning and in particular at the menstrual 
period, some drops of colostrum in the nipple. In the primiparae 
this sign becomes of influence in the diagnosis of possible pregnancy, 
but it is necessary to guard against making it a positive sign, for 
colostrum is sometimes met after prolonged genital excitations or 
in consequence of some uterine affections, even in virgins. 

2. Cessation of the menses. — The different causes of amenorrhoea, 
including pregnancy, may be arranged as follows : 

A. Extra-genital causes. 

1. Geneeal diseases. 

a. Acute. — Typhoid 'fever, etc., causing a simple passing 
amenorrhoea. 

h. Chronic. — Chlorosis; phthisis; poisoning; ansemia, from 
deprivation or unsanitary surrounding. In fact, any 
debilitating cause may produce amenorrhoea. 

2. Localized Diseases. 

a. Acute. — Any acute disease is capable of causing a mo- 
mentary amenorrhoea, A sudden impression, an 
emotion, the action of cold, an indigestion, the use of 
exciting drinks, certain medicaments (opium), bleed- 
ing, act the same. 

h. Chronic. — Prolonged suppuration, etc. Any cause of de- 
bilitation. Intestinal worms, by reflex reaction, cause 
amenorrhoea. 

B. Genital causes. 

1. Genital diseases. 

All diseases of the uterus and of the contiguous organs are 
capable, to different degrees, of causing a more or less 
prolonged amenorrhoea. Excess of coition or the first 
coition, may act in the same way. 

2. Physiological causes. * 

Pregnancy, lactation, menopause. 

3. Genital malfokmation. 

Absence or atrophy of the ovaries or of the uterus. 

4. Genital mutilations. 

Ablation of the ovaries or of the uterus. 
Cicatricial occlusion of the genital canal. 



162 The Diagnosis of Pregnancy. 

3. Augmentation of the volume of the uterus, — The different causes 
capable of producing an increase in the volume of the uterus are : 

I. Principal causes that may simulate an increase in the size of 

the uterus and that may produce errors : 
a. — Ovaries : cysts, cancer. 

h. — Broad ligaments : cysts, phlegmon, salpingitis. 
c, — Kectum : cancer. 
d. — Bladder : retention of urine, cancer. 
e. — Peritonaeum : pelvic peritonitis, extra-uterine pregnancy, 

hematocele. 
/. — Pelvis : osteo-sarcoma. 
g. — Tympanites, adipose, ascites, and all abdominal tumors 

causing an increase in the size of the abdomen. 

II. Cause of augmentation in the volume of the uterus : 
a. — Menstrual congestion. 

h. — Metritis. 

c. — Simple hypertrophy. 

d. — Hgematometra, physometra. 

e. — Mucous, fibroid, or papillary polypi. 

/. — Hydatid or dermoid cysts. 

g. — Fibroids (very frequent). 

h. — Sarcoma (very rare). 

i. — Cancer. 

j. — Normal or pathological pregnancy. 

Second three months. — The first part of pregnancy is characterized 
by the absence of the positive signs and the last by their presence. 
In the second three months, intermediate between these two periods, 
these signs appear : 

Sometimes, and rarely, at the beginning (fourth month). 
Sometimes, and generahy, in the middle of this period (fifth 

month). 
Sometimes, exceptionally late, toward its termination (sixth 

month) . 

Now, before the appearance of these positive signs the diagnosis 
presents under the same condition as in the first three months and 
we may relate it to the explanations given above. After their ap- 
pearance the diagnosis is much simplified and will be established 
as in the third and last three months which we now study. 

Third three months, — The existence of the positive signs generally 
renders diagnosis easy during this period. These signs are, as given : 

Palpation. 1. Abdominal ballottement. 

2. Active movements of the foetus. 
Auscultation. 3. Foetal heart sounds. 

4. xictive movements of the foetus. 



The Diagnosis of Pregnancy, 163 

Digital examination. 5. Vaginal ballottement. 

6. Detection of a foetal part. 

It will be remarked that among these signs, there are three which 
simply indicate the presence of the foetus, and three which permit 
us to say that it is living. These are : 

a. Signs of the presence of the foetus. 

1. Abdominal ballottement. 

2. Vaginal ballottement. 

3. Detection of a foetal part. 

b. Signs of the life of the foetus. 

1. Palpation of active movements. 

2. Audition of foetal heart sounds. 

3. Audition of active movements. 

These signs have already been studied in detail and I shall not 
return to them. 

B. Pathological pregnancy. — Numerous pathological states 
may complicate pregnancy and obscure its diagnosis. They will be 
studied in that part which is reserved for puerperal pathology. I 
shall siraply enumerate the principal conditions. These different 
complications are, passing from the periphery of the uterus toward 
the foetus : 

1. The various abdominal tumors; cysts of the ovary, hydrone- 
phrosis, ascites, and extra-uterine pregnancy. 

2. Malformations of the uterus ; double uterus. 

3. Diseases of the ovuline aiypenclages; hydatiform moles, hydram- 
nios, 

4. Death of the foetus, multiple pregnancy {2 to 5), monstrosities. 

5. Finally, the persistence of the menses during pregnancy. 

To complete this chapter there remain to be spoken of, the age of 
the pregnancy, that is, the probable date of delivery (discussed 
under the duration of pregnancy), the volume of the foetus and its 
situation in the uterus, and finally, the question relative to the 
probable sex of the child, so often asked of the accoucheur. 

Ahlfeld has attempted measurements to determine the dimensions 
of the foetus, but his results are of little practical value. To appre- 
ciate the volume of the child the obstetrician is reduced to an 
approximate estimation based on the knowledge derived from pal- 
pation. ■ 

We have seen the mode of determining the situation of the foetus 
during pregnancy, by palpation, auscultation and digital exami- 
nation, and it is useless to review this subject. 

With regard to the diagnosis of the sex of the child, a question 
nearly allied to that of procreation of the sexes at will, we are no 



164 Progress and Duration of Pregnancy. 

more advanced than in the time of Mauriceau, who thus expressed 
himself on this subject : "We can have no positive knowledge of the 
sex of the child which is in its mother's abdomen, and no knowledge 
of the means of begetting a boy rather than a girl." 



CHAPTER VIII. 



PROGRESS AND DURATION OF PREGNANCY. 
PROGNOSIS.— HYGIENE. 

A. Progress, — During the first three months the uterus, 
although but little developed, is the source of painful disturbances 
explained by reflex action — nausea and vomiting and the syncope. 
During the second three months these disturbances usually dis- 
appear. In the last three months the uterus becomes voluminous 
and attains the upper portion of the abdominal cavity, interrupting 
the action of the stomach and especially of the diaphragm. Below, 
it slowly invades the pelvis, disturbing the functions of the rectum 
and bladder. Finally, its size opposes the free circulation of the 
pelvis and lower limbs. 

B Duration. — To appreciate the average duration of preg- 
nancy, it is necessary to know exactly the moment of conception, 
that is, of the meeting of the male and female elements — 
spermatozoid and ovule. Unfortunately, our ignorance on this 
point is complete. In the most favorable circumstances, where 
there has been a single sexual connection affording exact infor- 
mation as to the moment when the spermatic fluid was deposited 
in the female genital organs, we are still at a loss as to the epoch 
of conception, for the spermatozoids, according to Schroeder, may 
preserve their fecundating properties for] fifteen days (perhaps 
more) before meeting the ovule. These fifteen days make exact 
calculation impossible. 

This vagueness enveloping the moment of conception naturally 
reacts on the fixation of the duration of pregnancy. How shall we 
decide on the duration of a state when we are ignorant as to its 
commencement ? To discuss the length of pregnancy and to attempt 
to fix it within one or two days is to take a perfectly useless trouble. 

However, it seems that we can admit, as an approximate and a 
provisory figure, nine solar months, or two hundred and seventy-five 
days. By leaving a contingent ten days, five before and five after, 



Progress and Duration of Pregnancy. 165 

we have the probable duration of pregnancy oscillating between 
two hundred and seventy and two hundred and eighty days. These 
figures, I repeat, only indicate the probabilities. Thus in presence 
of this uncertainty we are justly astonished to see authors dilate at 
great length on the study of prolonged j^regnancies. This idea of 
prolonged pregnancy has taken its source from various categories 
of observations : 

The first comprised the cases where the duration between the last 
menstruation and delivery has been greater than the usual time. I 
can cite a case where this duration was three hundred and thirty-five 
days, and cases of this kind are far from being rare. But in such 
cases it is wrong to suppose conception near the end of the last 
menstruation, since this can not be proven, and the negative can be 
supposed as well as the affirmative. 

The same is true of the second category of facts, where pregnancy 
has been the consequence of a single coitus, or of sexual relations 
taking place within a short interval of time. The possibility of a 
contingent fifteen days, during which the spermatozoids may live 
in the female genitalia makes cases of prolonged pregnancy, founded 
on this class of facts, still contestable. 

A third category of facts comprehends those where the volume of 
the foetus is greater than the average, and corresponds to a prolonged 
duration between the last menstruation, or a single coition and 
delivery. But as we have seen women delivered at the usual time 
of pregnancy of a very large foetus (4000 grammes and more), we 
can suppose from this that in the other case the duration of preg- 
nancy has been normal. 

Finally, in a fourth class, we shall rank those furnished by 
veterinary obstetrics. But in all these observations the prolongation 
of pregnancy remains doubtful, on account of the impossibility of 
determining the exact date of conception. There is nothing, then, 
permitting the affirmation of prolonged pregnancy, but it must also 
be added that there is no proof that obliges us to deny its possibility. 

It is not sufficient to know the approximate duration of preg- 
nancy, it is equally necessary to be able to predict the probable 
date of delivery. This determination will be based on the following 
signs : 

1. Signs furnished by interrogation. 
a. Signs of the commencement : 

1. Last menstruation. 

2. Single coition. 

3. Appearance of sympathetic phenomena. 
h. Sign in the middle period : 

4. First movements of the foetus. 
. c. Sign toward the end : 

5. Phenomena of descent of the uterus. 



166 Progress and Duration of Pregnancy. 

2. Signs furnished by direct examination. 

6. Volume of the uterus and of the foetus. 

7. Engagement of the foetal part. 

8. Modifications of the cervix. 

1. Last menstruation. — -The time which most often separates the 
last menstruation from delivery is two hundred and seventy-five 
to two hundred and eighty-two days, with a minimum of two hundred 
and forty-six days and a maximum of three hundred and twenty- 
eight days. 

2. Single coitus. — Delivery generally takes place at the end of two 
hundred and seventy-five days, that is, nine months after the fecun- 
dating coitus, with a possible deviation between two hundred and 
forty -two to three hundred and seventeen days. The special sen- 
sations felt by some women can only exceptionally be taken into 
consideration. 

3. Appearance of sympathetic phenomena. — It is rare that these 
phenomena (vomiting, syncope, development of varices,^ etc.) in- 
dicate the exact beginning of pregnancy, for in most cases they only 
appear some time after conception. However, some women, taught 
by a previous pregnancy, can sometimes recognize the beginning 
of pregnancy in this way. 

4. First movements of the foetus. — The first movements of the foetus 
are most often perceived in the course of the fifth month. Earely 
they occur before this, but they have been observed in the course of 
the fourth month. It is equally rare for them to appear for the first 
time during the last four months. Exceptionally women feel no 
foetal movements all through gestation although the foetus is per- 
fectly healthy. Few women can state exactly the precise date of 
the first foetal movements. When this moment is known, we shall 
be right in supposing that delivery will take place in about four 
months and a half, but this diagnostic point is very variable, for 
there may be a deviation of a month and even more. 

5. Phenomena of descent. — In the majority of cases the descent of 
the uterus appears nul, or we cannot determine it from the infor- 
mation furnished by the woman. The phenomenon of descent in the 
multiparae, when it exists, indicates that pregnancy is within the 
last fifteen days of its termination, but this is only simple proba- 
bility. In the primiparous woman its importance is nul. 

6. Volume of the uterus and foetus. — The volume of the uterus 
during pregnancy is too difficult to appreciate exactly, so that it 
yields scarcely any information as to the date of delivery. The 
height of the uterus in relation to the abdominal wall, however, in 
spite of the error to which it is exposed, furnishes valuable indices. 

In the relation we have : 

Fourth month. — Fundus of the uterus a little below the umbilicus. 



Progress and Duration of Pregnancy. 167 

Fifth month. — At the level of the umbilicus. 
Sixth month. — Fundus a little above the umbilicus. 
Seventh month. — Three fingers' breadth above the umbilicus. 
Eighth month. — Six fingers' breadth above the umbilicus. 
Ninth month. — Nine fingers' breadth above the umbilicus. 

7. Engagement of the foetal part. — Though the information fur- 
nished by the engagement of the foetus is quite vague, we can 
suppose, however, that in a primipara, with a deep engagement, 
delivery will occur in about a month, and in a multipara, with a 
deep engagement, delivery will not be later than fifteen days. But 
these figures are approximate. 

8. Modifications of the cervix. — On the supposition that the cervix 
is effaced during the latter part of pregnancy, we would have the 
right to diagnosticate the date of delivery from the length of the 
cervical part of the uterus. But as, save in exception, it is known 
to-day that effacement often occurs during labor, such reasoning 
cannot be admitted. 

With regard to the softening of the cervix, it is too variable in its 
progress, especially in multiparas, to constitute a important element 
of diagnosis. 

C. Prognosis. — "We can say, without exaggeration," writes 
Sacombe,* "from experience and observation, that pregnancy far 
from being a disease is, if I may express myself, a certificate of 
life for nine months that nature gives to the pregnant woman." 
To-day we believe, on the contrary, that the prognosis of the majority 
of diseases is aggravated by pregnancy. We shall see later, apropos 
of puerperal pathology, the influence of the different pathological 
states on pregnancy. 

With regard to the prognosis of the gestation itself, and especially 
of delivery, it depends upon divers circumstances, among which 
must be cited : 

1. The conformation of the pelvis. 

2. The situation of the foetus (presentation and position). 

3. The composition of the urine (albuminuria). 

From these comes the extreme importance of exact inquiry on 
these three points during the course of pregnancy. 

D. Hygiene of pregnancy. — 1. Digestive system. — Except in 
serious digestive disturbances, alimentation should not be modified 
during pregnancy. Women, usually constipated, are more so 
during pregnancy and need laxatives or enemas to avoid intestinal 
accumulation and violent efforts of defecation. Slight purgatives 
are without objection but drastic remedies should be avoided. .If 
diarrhoea occurs it should be combatted by the usual means. 

* Elements de la Science of Accouchements, i8oi, p. 93. 



168 Progress and Duration of Pregnancy. 

2. Breasts. — The clothes should not compress the mammary 
glands, so as to allow their physiological development. Apropos of 
lactation we shall see the special care to be given the nipples, w^iich 
demand preparation, a veritable education in view of this physio- 
logical function. 

3. Sexual relations. — The physician is often consulted for advice 
as to the continuance of sexual relations during pregnancy. In 
cases of irritable uterus and in women predisposed to abortion, all 
sexual relations should be interdicted during pregnancy, especially 
at a time corresponding to menstruation. It will even be wise to 
prescribe separate beds for the husband and wife, the vicinity of 
the husband often causing a genital excitement that is unfavorable 
to the calm required by the uterus for its normal development. 

4. Medicaments and operations. — Any drug given in a tonic dose 
is capable of producing abortion. Eemedies prescribed during 
pregnancy, then, should be given in relatively small doses. There 
are some exceptions, however, for example, mercury in syphilis, 
and sulphate of quinine in malaria, where an energetic action is 
necessary. 

Can a pregnant w^oman undergo, without inconvenience, a surgical 
operation ? This question should be viewed from two standpoints : 

1. Does pregnancy interfere with the consequences of an oper- 
ation ? The answer is negative for the majority of cases. Gestation 
does not appear to interrupt cicatrization nor predispose to com- 
plications. 

2. May the operation interrupt the course of pregnancy ? Every 
operation exposes to abortion, and this danger increases as the 
genital zone is approached. But very often intervention interesting 
the uterus itself (amputation of the cervix, ablation of fibroids de- 
veloped in the uterine wall) have not been followed by any unfor- 
tunate result. Besides the danger of abortion is not in relation with 
the gravity of the operation, as some women continue their gestation 
in spite of an ovariotomy, while others abort after the extraction of 
a tooth. In the presence of this variability of results it is prudent 
to perform during pregnancy only operations of necessity. 

3. Professions. — Certain prof essions are unfavorable to the normal 
evolution of pregnancy. Some are exposed to poisoning, such as 
workers in lead, caoutchouc (sulphide of carbon), tobacco, others to 
excessive fatigue, as laundresses, shop girls, sewing-machine oper- 
ators, etc. 

4. Clothing. — All tight clothing should be proscribed. The corset 
should be as loose as possible. In women predisposed to varices or 
oedema of the lower limbs the garters should be replaced by suspend- 
ing the stockings by bands attached to the corset. The use of im- 
proper shoes should be avoided. In nulliparous women the relaxation 



Progress and Duration of Pregnancy. 169 

of the abdomen may be greatly relieved by the use of a hypo- 
gastric belt on condition that it is large and embraces the lower two- 
thirds of the abdomen. 

5. Exercise and voyages. — Some women, naturally indolent, profit 
in their pregnant state by confining themselves to an exaggerated 
repose. This practice is deplorable, daily exercise is necessary. 
On the contrary we must restrain the imprudent who, in spite of 
their condition, continue their former habits, going to balls, theatres, 
etc. Carriage riding is generally favorable. It is wise to dissuade 
from horsemanship. According to Irwin, sea voyages predispose 
to menorrhagias, while Kugelman states that railway journeys pro- 
duce delay of the menses. This would be an interesting difference 
if clearly established. However, in the majority of cases normal 
pregnancy is not interrupted by these factors, even prolonged. But 
in women disposed to abortion prudence should be advised. 

6. Toilet. — Women often inquire if they can continue the use of 
cold water for their ablutions, the same as before pregnancy. With 
regard to this no change of habit is necessary. Hot foot-baths 
should be avoided. Sea bathing is not objectionable, but fatigue 
should be avoided. Hot baths are favorable, on condition of being 
short (not over a quarter hour) and being taken at 30^ to 35^ C. 

The vulvar toilet is hygienic, but vaginal injections should be 
proscribed before the last fifteen days of pregnancy. These in- 
jections may be necessary, however, in some cases, where there 
exists a vaginitis, for example. During the last fifteen days it is 
well, in an antiseptic point of view, to advise a daily injection of a 
bichloride of mercury solution (1-4000). 



170 Accouchement. — Maternal Phenomena, 



CHAPTER IX. 



ACCOUCHEMENT.— MATERNAL PHENOMENA. 

Accouchement is the expulsion of the ovum from the maternal 
organism, whether the ovum be in the uterus, as in the normal state, 
or outside it, as in extra-uterine pregnancy. According to the 
period at which this takes place accouchement receives various de- 
nominations : 

1. During the first six months — abortion. 

2. During the last three months — premature accouchement. 

3. At normal term — accouchement at term. 

4. After normal term — delayed accouchement. 

Accouchement is generally made in two stages : 

First stage, expulsion of the foetus. 

Second stage, expulsion of the appendages. 
There are then two successive deliveries : 

1. Foetal expulsion or accouchement properly so-called. 

2. Accouchement of the annexes or delivery. 

Foetal accouchement. — The term accouchement employed 
alone will be applied exclusively to the foetal expulsion, as opposed 
to delivery, that will be reserved to designate the expulsion of the 
appendages. 

Labor is almost synonymous with accouchement; however, this 
word applies more particularly to the modifications of the genital 
organs which prepare for the expulsion (uterine contraction, opening 
of the parturient canal, etc.). 

Considered according to its difficulties accouchment is called : 

1. Normal, physiological, entocic, when the foetus presents by the 
vertex and when no difdculties arise. 

2. Abnormal, pathological, dystocic, in contrary conditions. 
Or again : 

1. Spontaneous, when it is left to the forces of nature alone. 

2. Artificial, if intervention is necessary. However, a slight inter- 
vention, for example that which consists in aiding the rotation of 
the head with the finger, is not considered as constituting an arti- 
ficial accouchement. Besides, these limits are arbitrary. 

Maternal phenomena. — The contraction of the uterus and its 
accessory, that of the abdominal wall, causes the successive opening 



Accouchement, — Maternal Phenomena. 171 

of the cervix, of the vagina, and of the vulva. Contraction is then 
the cause and the opening the effect. We shaU study these two 
phenomena ; one etiological, the other the result. 

A. Uterine contractions. — The uterine contraction presents three 
essential characteristics, it is painful, intermittent and involuntary. 

Painful. — The pain is the dominant character of the uterine con- 
traction to such an extent that, in common language, these two 
words are taken (wrongly) as synonyms. It establishes the dif- 
ference between the uterine contractions of pregnancy and those of 
labor. The woman suffers only at the moment when labor com- 
mences. 

Its intensity is quite variable. Some women are delivered with- 
out a trace of pain. Others suffer so dreadfully that they prefer to 
die and even seek death. 

The character of the pains varies according to the peiiod of labor. 
a. Period of clilatation of the cervix. 

1. Initial pains, — Slight pains in the hypogastrium, in the flanks 
and especially in the lumbar region. 

2. Preparatory pains, — Sharper than the preceding; occupying 
the same situation and sometimes radiating along the thighs, in the 
track of the crural nerve. 

h. Period of expulsion. 

1. Expidsive pains. — The pain takes a new character, because the 
woman at each contraction feels the need of bearing down. Each 
pain is accompanied then by a more or less energetic effort in this 
direction. The radiations along the lower limbs are still frequent 
but occupy by preference the course of the sciatic. 

2. Conquassant pains. — These are the terminal expulsive pains, of 
accrued intensity, from the excessive dilatation of the vulva at the 
moment of the passage of the foetal head. 

The cause of the pain during uterine contractions has been the 
subject of long discussions. But it is known that the pathological 
or energetic contraction of every organ provided with smooth mus- 
cular fibres produces a pain designated as colic. Now, the pains 
of accouchement are only uterine colic. All the uterus is painful 
during uterine contraction, thus, at this moment compression of 
the abdomen and palpation are painful to the woman. Digital 
examination is equally painful when the finger drags on the external 
orifice of the uterus. Generally the pain disappears in the interval 
of the contractions. However, when the contractions are very fre- 
quent or very energetic, as at the end of labor, it is not rare to see 
them almost continuous, with exacerbation at the moment of 
muscular activity. 

In the early part of labor, during the initial contractions, the 



172 Accouchement. — Maternal Phenomena. 

patient, who is walking to and fro, stops, supports herself on a 
chair and inclines forward. She becomes quiet, the face contracts, 
some oscillations show the mute suffermg, then the calm returns 
and the patient is momentarily free. Later the pains, becoming 
more intense, elicit cries, clamorous complaints, mixed with words 
of despair. These cries are more and more marked as dilatation 
progresses. 

During expulsion efforts complicating the situation modify the 
nature of the cries and permit a practiced ear to easily recognize 
this last period of labor. 

Intermittent. — 

Initial pains, repeated every twenty minutes, duration 

thirty seconds.* 
Preparatory pains, repeated every ten minutes, duration 

sixty seconds. 
Expulsive pains, repeated every five minutes, duration 

ninety seconds. 
Conquassant, almost continuous. 

The intermittent character of the contractions permit repose for 
the uterus and the re-establishment of the foetal circulation, which 
is more or less disturbed during uterine systole. A prolonged con- 
traction, that is, uterine tetanus, causes death of the foetus by the 
arrest of its circulation. 

Involuntary. — As in all the unstriated muscular structures, the 
contractions of the uterus are independent of the will. However, 
some conditions are capable of reflex action, of modifying the in- 
tensity or the frequence of the contractions. Thus they are seen to- 
diminish under the influence of an emotion or in the presence of 
a person disagreeable to the patient. 

In opposition to the uterine contractions, those of the abdominal 
walls are essentially voluntary, and some women can retard or ad- 
vance delivery by regulating their intensity. 

Some words on the results of uterine contraction. The uterus by 
contracting diminishes the vertical and antero-posterior. We have 
seen the influence of the contraction on the foetal circulation. The 
number of maternal pulsations is, on the contrary, increased 
throughout its duration (Fig. 197). When the bag of waters is 
ruptured, there is a slight flow of the liquor amnii at the beginning 
and the end of ihe contraction. The force of the uterine contraction 
varies from one to twenty kilogrammes, and can be fixed at an 
average of ten kilogrammes. The assistance of the abdominal con- 
traction is capable of increasing this force to three and even to four 
times the power (thirty to forty kilogrammes). 

B. Abdominal contractions. — The contraction of the abdominal 

♦These figures only represent the average, they are subject to great variation. 



Accouchement, — Maternal Phenomena, 173 

muscles, that is, the expulsive effort, follows at an advanced period 
of labor, usually when the dilatation of the uterine orifice is com- 
plete and when the foetal part is supported on the perinseum. It 
commences a little after the beginning of the uterine contraction 
and ceases a little before its termination. The expulsive effort is 
not always single during a uterine contraction, three, four or five 
efforts may be observed. The abdominal contraction depends upon 
the will, but the need of bearing down is so imperiously impressed 
on the woman that she cannot restrain from it. The expulsive 
effort may exist without uterine contraction, and take place some- 
times under the direction of the accoucheur to terminate a very 
much advanced expulsion. 

Uterine contractions. 



Maternal pulsations. . 
N 



Foetal pulsations. ^ 




Fig. 197. — Influence of uterine contraction on the 
foetal and maternal pulsations. 

C. Vaginal contractions. — The vagina, endowed with an unstriated 
muscular coat, is contractile, but the contractions of this canal are 
so feeble that their role seems almost nul in accouchement and very 
rudimentary in delivery itself. 

II. Opening of the cervix, of the vagina and of the vulva. — The two 
canals which must successively open and allow the passage of the 
foetus are : 

The cervix uteri, to wMch must be added the inferior segment of 
the uterus. 

The vagina, terminated by the vulva and sustained by the peri- 
naeum. 

Let us study these two successive openings : 

A. Dilatation of the cervix. — At term, the uterus is constricted by 
three parts (Fig. 198). An upper thick part, called the superior 
segment of the uterus (divided by some authors into median and 
superior segments). A thin intermediate portion, separated from 
the preceding by the uterine circle (or Bandl's ring). This is the 
inferior segment of the uterus. An inferior portion is comprised 
between the external and the internal orifice constitutes the cervix. 

The superior segment is formed by the body of the uterus, the 
cervix remains as it was before pregnancy, but with regard to the 
origin of the inferior segment there are three theories. The first, 
that of Brandl and Braune, attribute its formation exclusively to 
the cervix. The uterine circle would be the internal orifice and the 



174 Accouchement. — Maternal Phenomena, 

efPacement of the cervix would constitute the inferior segment. The 
second theory is also from Bandl, who, modifying his first views 
admits that the inferior segment is formed in part by the cervix and 
in part by the body of the uterus. Finally, AYaldeyer and Hofmeier 
have sustained a third theory, according to which the inferior 
segment is formed exclusively by the body of the uterus. 




Uterine circle. 
Internal orifice. 

External orifice. 



Fig. 198. — Uterus at the beginning of accouchement. 

I believe it can be demonstrated that no one of these explanations 
is satisfactory. The uterus in the normal state and before con- 
ception is composed, in fact, of three parts: The body; the 
isthmus ; the cervix. Now, at the end of pregnancy, the body con- 
stitutes the superior segment of the uterus. The isthmus, the 
inferior segment. The cervix remains intact. The schemas 199, 
200 and 201 present a resume of my idea. 



Cervix. _._._\ \ / / 

Fig. 199. — Uterus at the beginning of pregnancy. The inferior segment 
is at this period of pregnancy formed by the body. 

Thus understanding the inferior segment and the cervix, we may 
study the effect of the uterine contractions in dilating these parts 



Accouchement. — Maternal Phenomena. 



175 



for the passage of the foetus. Let us suppose a section of the 
inferior part of the gravid uterus (Figs. 202 to 208). 



Sup. segment.- 
Inf. segment. * 




Cervix, 



Fig. 200. — Uterus at the end of pregnancy. The inferior segment 
is formed by the isthmus. 




Cervix effaced. ^,---— ** 

Fig, 20I. — Uterus during labor. The inferior segment is at this moment 
(labor) formed by the isthmus and cervix. 




Figs. 202 to 208. — Effacement of the cervix and dilatation of the external orifice. 

(Fig. 202, cervix not effaced; Fig. 203, cervix being effaced; Fig. 204, cervix being 
effaced: Fig. 205, cervix effaced; Fig. 206, dilatation of external orifice; Fig. 207, 
dilatation of external orifice; Fig. 208, dilatation of external orifice.) 



176 Accouche me) it. — Maternal Phenomena. 

The point a is the section of the uterine circle. 

The point h is the section of the internal orifice. 

The point c is the section of the external orifice. 

The line ah represents the wall of the inferior segment. 

The line ch represents the wall of the cervix. 

The point cl marks the section of an orifice of new formation 
(Muller's orifice). 

Now the opening as in figures 202 to 205 is called effacement. 
While that occurring in figures 205 to 208 is called dilatation (of 
the external orifice). Effacement, then, is the disappearance of 
the cervix, its fusion with the body of the uterus, or better, the 
fusion of the cavity of the cervix with that of the body of the uterus. 
Dilatation is the opening of a simple diaphragm, which, after 
effacement, separates the uterine cavity from the vaginal cavity. 
But there is no advantage in thus limiting the word dilatation, and 
it is better to apply it also to the opening of the internal orifice and 
to the cervical cavity as well as to that of the external orifice. 
When there have been indicated the length of the cervix (that is, the 
degree of effacement), the degree of dilatation of the external orifice, 
of the cervical cavity (if it exist) and of the internal orifice (if still 
remaining), the explanation is sufficiently clear. 

When it opens progressively under the influence of the internal 
contraction, the external orifice is : 
Sometimes circular. 
Sometimes oval. 
Sometimes irregular (cicatrices — cancer). 

The thickness of the cervix varies according to the parity : In .the 
primipara there is a marked thinning ; the edge of the orifice gives 
a sensation analogous to that felt in touching the frsenum of the 
tongue. In the multipara, on the contrary, the contour of the 
cervix is thick, analogous to the lips slightly drawn over the teeth 
by their intrinsic muscles. 

The rapidity of the dilatation of the external orifice varies with 
parity (about ten hours in the primipara, five hours in the multi- 
para), with the vigor of the uterine contraction, with the state of 
the softening of the cervix, with the presentation, with the state of 
the pelvis, etc. It progresses more rapidly in proportion as it 
advances. Its progression is generally regular; however, it is not 
rare to observe an arrest during a half hour, an hour, or even 
more. This interruption may be renewed several times. Some- 
times the external orifice after dilatation to the extent of two to three 
finger's breadth may even reform. The pregnancy resumes its 
normal course to a reappearance of labor after a variable time. 
This has been designated as retrocession of labor. 

During dilatation of the external orifice various complications 
may occur. Among these I shall mention oedema and lacerations. 



Accouchement, — Maternal Phenomena. 



Ill 



CEclema is sometimes generalized around the cervix, as often ob- 
served in some cases of prolonged labor. In the multipara it 
invades and thickens the free border of the orifice (Fig. 209). In 
the primipara it respects the free border, which preserves its char- 
acteristic thinness (Fig. 210). Sometimes it is localized to a portion 
of the cervix, almost always to the anterior lip, as observed by 
preference in the occipito-posterior positions on account of the com- 
pression exercised by the forehead against the pubes. 





Fig. 209. — CEdema of the cervix in the multipara. 





Fig. 210. — CEdema of the cervix in the primipara. 

Lacerations, — The foetal part pushed too violently by the utero- 
abdominal contraction, sometimes produces true tears which are 
shown (Fig. 211) : 




Fig 211.— Laceiations of the cervix. 



I. Sometimes as a simple slit, most frequently to the left, on 
account of the most frequent situation of the occiput to this side. 

II. Sometimes as a strip ; the path of tliis laceration leaves the 
orifice and curves parallel to the periphery of the cervix. 



178 



Accouchement. — Maternal Phenomena, 



III. Sometimes as a button-hole, without affecting external os. 

IV. Sometimes as a circular button- hole, which detaches all the 
inferior portion of the cervix, separating it and leaving it as though 
set in a socket. 




Fig. 212. 

Dilatation of one 
finger's breadth. 




Fig. 213. 

Dilatation of two 
finger's breadth. 




Fig. 214. 

Dilatation of three 
finger's breadth. 




Fig. 215. 

Dilatation of four 
finger's breadth. 



Fig. 2x6. 

Dilatation of five 

finger's breadth or 

palm of the hand. 




Fig. 217. 

Dilatation of six 

finger's breadth 

or complete. 



Fig. 218. — Perinaeal ampliation during accouchement. 

The degree of dilatation of the external cervix is estimated by 
the sense of touch. The older authors expressed the degrees of 
dilatation in comparison with the size of various pieces of money, 



Accouchement. — Maternal Phenomena. 179 

then with that of the palm of the hand and finally as complete. 
Some modern authors, particularly Budin, have proposed esti- 
mation in centimetres. But pieces of money vary in different 
countries and the metric system has not been universally adopted 
so that it is preferable to estimate the degrees of dilatation in 
finger breadths (Figs. 212-217). 

Dilatation is called complete when the periphery of the external 
orifice is in contact with the pelvic ring. It is called sufficient when 
it permits the passage of the foetus. This last condition is relative 
to the volume of the child. In the diagnosis of the degree of dila- 
tation, it is necessary to keep in mind some causes of error. These 
are : A circular vaginal fold. Folds of the scalp. Large bag of 
water. Thinning of the cervico-uterine segment. Deviation of the 
uterine orifice. It is sufficient to know these, to be able to avoid 
error. 

B. Opening of the vagina and vulva. — The vagina, of which the 
vulva may be considered the external orifice, opposes by itself 
only a feeble resistence to the progression of the fcetal part. The 
hymen alone, in some primiparse, is capable of causing an obstacle 
of some importance. But the vagina lies on the perinseum, which, 
especially in the primiparse, opposes a serious resistance to the exit 
of the foetus. From this arises the necessity, for the vagina as for 
the cervix, of a veritable labor before permitting accouchement. For 
the description of the vagino-vulvar dilatation, I shall suppose a 
presentation of the vertex, the most common. The uterus contracts 
and aided by bearing- down it pushes the cephalic extremity into 
the vaginal canal, which has a direction perpendicular to the uterine 
axis. In this way the foetal head, forced parallel to the uterine 
axis, tends to gouge into the perinseum (Fig. 218). The perinseum, 
essentially contractile and retractile, reacts against this pushing 
from the uterus, and the effect of these two forces combined is to 
direct the foetal part toward the vulvar orifice. 

The perinaeum constitutes a sort of door, swinging one way, 
flexible^ with the sacro-coccygeal articulation representing the hinge, 
and the inferior part of the vulvar orifice the free side. This door 
opens under the foetal pressure, first in its posterior part, or coccy- 
anal, then in its anterier part, or ano- vulvar. 

1. Coccy-anal amioliation. — The head presses first on the coccyx, 
which it pushes backward. But the coccyx, solidly maintained on 
each side by the fibers of the perinaeal levator, opposes a serious 
obstacle to the passage of the head. 

2. Ano-vulvar ampliation. — The progression continues. The anus 
opens by degrees (Fig. 219). The head at this moment appears at 
the vulva then retreats in the interval between the contractions. 
At each new effort the head advances a little more and dilates the 



180 



Accouchement. — Maternal Phenomena. 



vulvo-vaginal orifice. Finally, by a swinging movement the head 
issues distending the perinaeum to the maximum and dragging it 
forward. As soon as the most voluminous part of the foetal region 
has passed, the perinaeum, which has been drawn out, retreats un- 
covering the foetal part. The first part of accouchement is com- 
pleted, one of the ovoids has made its exit and the other escapes by 
an analogous mechanism. The perinaeal opening has been dilated 
by the first ovoid, so that the passage of the second is made with a 
relative facility. 




Fig. 21 8. — Perinaeal ampliation during accouchement. 




Fig. 219. — Perineo-vulvar ampliation. 



Opening of the anus. 



During this ampliation the perinaeum undergoes an enormous 
transverse distention, and especially antero-posterior, so that the 
distance which extends from the inferior extremity of the sacrum 



Accouchement. — Maternal Phenomena. 181 

io the fourchette approximately arrives at twenty centimetres, four 
for the anus and about eight for the retro-anal (comprising the 
coccyx) part and eight for the ante-anal part. Even this distance 
may be exceeded. 



' I ,a 




Fig. 220. — Perinaeal profile. Perinseal lacerations. Different degrees. 

One of the most frequent complications of accouchement is con- 
stituted by wounds of the vulva and of the perinseum. We might 
say these wounds are the rule, for out of one hundred cases I only 
found the vulva intact in five. Leaving to one side the ecchymoses, 
which compose the first degree of ^oilvar traumatisms, we can 
divide wounds of this region into three categories : 

1. Those which affect the inferior or posterior part of the vulva. 

2. Those which occujDy the latero-posterior regions. 

3. Finally, the complex wounds — mixed wounds combining the 
two preceding. 

1. Inferior and posterior ivounds. — Wounds of the inferior or pos- 
terior part of the vulva are those wliich are usually designated as 
lacerations of the perinaeum. They may be marginal (Fig. 220) or 
central (Fig. 221). 

2. Latero- superior ivounds. — As in posterior wounds it is necessary 
to establish here the distinction between marginal and central 
laceration. The marginal lacerations extend outward from the 
^-ulvo- vaginal orifice or its vicinity and are directed toward the free 
border of the labia minora which they may attain (Figs. 222 to 225). 
The central lacerations produce a veritable perforation of the labia 
minora, analogous to the central laceration of the perinaBum (Fig. 
226). 

3. Complex wounds. — Complex wounds are constituted by the 
association of the two preceding varieties. I shall not return to 
their description. The number of wounds wliich may affect the 
vulva is variable. They may even amount to eight as I have seen 
(Fig. 227). 



182 



Accouchement. — Maternal Phenomena. 



Prognosis. — Vulvar lacerations expose to two important accidents : 
for one part, to haemorrhage at the moment of accouchement, es- 
pecially when an artery, a dilated vein (varices) or a vascular organ 
like the clitoris, is affected ; for the other part, during post-partum, 
to haemorrhage. Wounds well cared for reunite, at the perinaeum 
most often by first intention, at the latero-superior part of the 
vulva, by first intention in some cases, in others, and more often, 
by second intention. 



Vulva. 



Central 
laceration. 



Anu$. 




Fig. 221. — Central laceration of the perinseum (J. Y. Simpson). 

Treatment. — The treatment of vulvar lacerations is preventive 
and curative. 



A. Preventive treatment. — 1. Perinceo-vulvar dilatation. — Formerly 
a series of manoeuvres were practiced to hasten the opening of the 
vulva and of the cervix, but these have been justly abandoned, for 



Accouchement. — Maternal Phenomena. 



18a 



their influence is more unfavorable than salutary. Others have 
advised various methods, such as drawing back the perinaeum with 
two fingers, or using three fingers in the form of a cone, to afford a 
prsefoetal dilatation. 





Fig. 222. — Two lacerations. 



Fig. 223. — Three lacerations. 





F[G. 224. — Three lacerations, one of 
which affects the free border of the right 
labia minora. 



FiG. 225. — Three lacerations, one of 
which affects the free border of the left 
labia minora and another the fourchette. 



2. Perincso-vulvar support. — In the double aim of moderating the 
rapidity of the foetal exit and of giving the foetus the direction de- 
manding the least distention of the maternal parts, it is important 
to support the perinaeum. For this the hands will be placed dif- 
ferently according to the position taken by the woman during labor. 



184 



A ccouchement. — Maternal Phenomena. 





Fig. 226. — Perforation of the left labia 
minora (black point). 



Fig. 227. — Complex wounds of the 

vulva (8). 



In the dorsal position, the buttocks are uplifted by means of a 
cushion, in such a way as to permit easy inspection of the genital 
organs. The legs are flexed and the thighs widely separated. The 
physician placed to the right of the w^oman, passes the right hand 
under her right thigh and applies it on the perinseum (Fig. 228), 
taking care not to cover the fourchette, so that the eye can follow 
its modifications. The other hand is placed on the foetal head to 
maintain it. The foetal part is thus solidly held by the accoucheur, 
directly by the upper hand, mediately through the perinseum by the 
lower one. Its exit is thus regulated at will. 

In the lateral position the woman is placed so that the buttocks 
correspond to the edge of the bed and the thighs are flexed, making 
almost a right angle with the trunk. The upper thigh should be a 
little more flexed than the lower and between them will be placed a 
pillow rolled on itself, or any cushion, to keep the limbs separated. 
The right hand (Fig. 229) supports the perinaeum, as in the dorsal 
position, the other passed around the upper thigh supports the head. 

3. Episiotoniy. — To avoid extended tears of the perinseum vulvar 
incisions have been proposed. The different procedures advised 
are united in the schema of Figure 280. 

Eitgen, — A series of radial incisions. 

Eichelberg. — One or two large latero-inferior incisions. 

Michaelis. — Posterior incision. 

Tarnier and Chantreuil. — Incision of Michaelis completed in- 
feriorly, either on a single side (in L), or on both sides (in a re- 
versed Y). 



A ccoiichement. — Maternal Phenomena. 



185 




Fig. 228. — Dorsal or French position. 




?$^ 




Fig. 229.— Lateral or English position. 



180 Accouchement. — Maternal Phenomena, 

These incisions can be made with the scissors or with a blunt- 
pointed bistoury. 



r 



cr. 



/ 



y i 

y < 

/ ETcbelberg X 

\» I 
\ i 

Fig. 230. — Different procedures of episiotomy. 

Bitgen's procedure is insufficient. That of Eicheiberg has, it is 
said, the disadvantage of often wounding the duct of BarthoHn's 
gland, and of causing section of nervous filaments that remain pain- 
ful after cicatrization. Michaelis' procedure, completed at need by 
the incisions advised by Tarnier and Chantreuil, appears inferior to 
that of Eicheiberg and I believe the disadvantages of the latter have 
been exaggerated. 

B. Curative treatment. — When the perinseal lacerations are of 
small extent, not exceeding half of the vulvo-anal portion, they 
often cicatrize by first intention, provided the lower limbs are tied 
together at the knees for two or three days. 

To keep the two lips of the wound together the employment of 
serre-fines has been advised. But applied on the perinaeum they 
are easily displaced, cause painful dragging and are, in a word, in- 
ferior to sutures. 

Perineorrhaphy should be performed every time the perinseal 
laceration is of much extent, and especially if it is complicated. 
As a contra-indication has been given a too marked contusion after 
a laborious accouchement, but it is always better to attempt an 
immediate perineorrhaphy, being prepared to see it fail in unfavor- 
able cases. 

Leaving aside the latero- superior wounds, which rarely claim 
attention, the therapeutics of lacerations will be as follows : 



Accouchement. — Maternal Phenomena. 



187 



1. Laceration of the first degree (limited to the fourchette), no 
treatment necessary. 

2. Laceration of the second degree (from the fourchette to the 
anus) (Fig. 231). 

a. SHght laceration. Simple fixation of the lower limbs together 
for one to three days. No sutures unless the patient is unruly or 
the nurse inexperienced. 

h. Extended laceration. Superposed sutures, one centimeter apart. 





vrenuc 



Fig. 2^1. — Serre-fine. 



CfiRVJDC 
E.U/IS. 

VABINA 

Fig. 232. — Genital passage. 



3. Laceration of the third degree (or complicated) : a deep and 
extended suture, a series of sutures as in the preceding case. At 
need, buried suture of the recto-vaginal septum. In the case of 
central laceration of the perinseum, we also have recourse to 
sutures, uniting the separated surfaces in all their extent. 

Arrived at the close of tliis study of the maternal phenomena, let 
us take the whole at a glance. The schema of Fig. 232 represents 
the canal through which the fcetus must pass from the fundus of 
the uterus. The thick part expels the foetus by its contraction, its 
role is essentially active ; the thin part, on the contrary, is a long 
irregular sphincter wliich, both active and passive, opens and 
dilates to allow the passage of the uterine contents. Accouchement 
is only the struggle between the thick part and the thin part of the 
genital organs. Delivery (extended to the expulsion of all the 
ovum) is the victory of the thick segment over the thin segment ; it 
is the denouement of the struggle wiiich lasts a variable time. 



188 



Accouchement. — Phenomena of the Appendages. 



ACCOUCHEMENT.— PHENOMENA OF THE 
APPENDAGES. 

A. Bag ofivaters. — The bag of waters is constituted by that part 
of the ovuline membranes left bare by the dilatation of the uterine 
orifice. It is necessary to avoid, as too often occurs, the use of the 
term ovuline membranes as a synonym for bag of waters, for the 
latter represents only a part of these membranes. Its formation 
is caused by the dilatation of the cervix. The bag of waters may 
present any one of the various forms of the schema in Fig. 233. In 
the first variety (flat) there is only a thin layer of liquid interposed 
between the foetal part and the membranes. In the projecting 
variety we have, according to the degree : {a) the hemispherical 
form ; (b) the cylindrical form ; (c) the piriform variety. 




Fig. 233. — Different varities of the bag of waters. 

The bag of waters is smooth when it is formed by a portion of 
the membranes distant from the placenta, but it becomes more and 
more unequal as it approaches the placental disc. These inequal- 
ities may serve as a guide to the probable situation of the placenta. 
Sometimes it happens that the finger, passed over the membrane, 
perceives in their thickness pulsations synchi'onous with the foetal 



Accouchement. — Phenomena of ihe Appendages. 189 

pulsations. This sign reveals the presence of vessels passing to an 
accessory or erratic cotyledon or to a velamentous insertion of the 
cord. 

The membranes are permeable, so that the surface of the bag of 
waters always presents a marked humidity. This permeability 
plays an important part in the formation of "the show." 

At a given moment the membranes rupture, the amniotic liquid 
is liberated, the ovum is open. By studying the mode of rupture 
of the membranes we shall see at the same time the constitution of 
the bag of waters. The membranes may rupture in two totally dif- 
ferent ways, successively, or as a whole. 

Successive rupture takes place as follows : The cervix opening 
and giving passage to the foetus, the portion of the membranes 
which descends first and constitutes the bag of waters undergoes a 
notable distention, much more marked than the rest of the ovuline 
envelopes. The decidua, the most superficial, soon ruptures leaving 
uncovered a pait of the chorion. The chorion and the amnion, 
pushed as a whole by the liquor amnii, protrude through the open- 
ing formed by the rupture of the decidua. The pushing continues, 
the projection increases and a new rupture follows, but contrary to 
what might be thought, on account of the elasticity of the chorion 
compared with the resistance of the amnion, it is the chorion which 
ruptures first. This is because its adhesion to the decidua prevents 
its descent or gliding on this membrane ; all its ampliation at the 
bag of waters is made exclusively by its elasticity and not by gliding. 
For the amnion, on the contrary, though of little marked elasticity, 
gliding is easy on account of its feeble adhesion to the chorion, so 
that it descends without difficulty. Thus a rupture of the chorion 
before the amnion will be comprehended. 

The amnion remaining alone, to constitute the bag of water, con- 
tinues to glide. The bag descends, pushed by the amniotic liquid 
and the fcetal part. This gliding of the amnion produces the de- 
tachment that is easily found by examination of the appendages 
after delivery. When this gliding is interrupted by any cause, 
compression between the foetal part and the uterine wall, adhesion, 
placenta inserted in the inferior segment, too great thinness of the 
membrane itself, or finally under the influence of intervention by 
the accoucheur, rupture takes place as for the chorion and decidua, 
the ovum is opened, the amniotic liquid flows away, and the foetus 
passes through tliis opening by enlarging it. 

Aside from this successive rupture, there exists rupture as a. 
whole, at once. The three membranes are ruptured at the same 
place. Their union remains intimate, they all three succumb at once. 

According to the results I have obtained, the rupture as a whole 
takes place in 46 per cent of cases ; successive rupture takes place 
in 54 per cent of cases. Successive is then the most frequent. 



190 Accouchement. — Phenomena of the Aj^pendages. 

The situation of the rapture is variable and raay occur in different 
places (Fig. 234, 12 3). 




Fig. 234. — Different places of rupture of the membranes. 

In relation to accouchement the rupture may occur : 

Before labor — premature rupture. 

During labor — 1. During the dilatation of the cervix (precocious 
rupture) ; 2. at complete dilatation (tempestive rupture) ; 3. during 
expulsion (late rupture). 

After labor — delayed rupture. 

Premature rupture takes place fifteen days, a month, sometimes 
even more, before accouchement. I have seen a case where it 
occurred fifty days before labor, which was at the beginning of the 
ninth month. 

Eetarded rupture, that is, after the ovum has been expelled as a 
whole and at term is quite exceptional (four to five cases). In ex- 
pulsion before term, it is never frequent. 

I have put in parenthesis the terms "precocious, tempestive and 
late rupture" for I do not admit these distinctions based on the 
erroneous opinion that the bag of waters should rupture at complete 
dilatation in the physiological state. 

It is probable, save some exceptions, that the rupture of the bag 
of waters is as much more favorable to accouchement as it is late. 
Its integrity presents a double advantage. The risks to the foetus 
are less when the ovum is complete. With regard to the mother, 
it is certain that the bag of waters, forming an advance guard for 
the foetal part, favors the dilatation of the cervix and the ampli- 
ation of the perinaeum and of the vulva. This cushion of waters, 
spreading humidity before it, exercises a soft pressure which the 
maternal tissues obey better than the rude compression exercised 
by the foetal part. 



Accouchement. — Phenomena of the A.iJjpendages. 191 

"Whatever may be the moment of accouchement ^vhen rupture 
occurs, it takes place, sometimes silently, sometimes with a noise. 
The difference depends upon the quantity of water, which may be 
free to flow at the moment of rupture. 

The diagnosis of the rupture of the bag of waters, generally easy, 
may be of excessive difficulty sometimes. Whenever intervention 
is necessary, and notably the application of the forceps, this diag- 
nosis, however, is indispensable. In cases of a premature flow of 
the liquor amnii, the knowledge of the rupture of the ovum is the 
basis of a prognosis. 

For the answer to this question we have three elements : 

1. The shiinkage of the abdomen. 

2. The flow of liquid. 

3. Digital examination. 

1. The shrinkage of the abdomen. — The rupture of the ovum, some- 
times causing the evacuation of a large quantity of liquid, may 
diminish the abdomen so markedly that the patient, and even the 
accoucheur, mil perceive it. However, this sign is too vague to 
constitute more than an adjuvant. 

2. The floiv of liquid. — When liquid, of the same color as the 
liquor amnii flows trom the vagina, after having eliminated the 
possibility of an involuntary or unconscious micturition, we may 
question whether this is the show or the pure amniotic liquid. 

Differential signs : 

THE SHOW. LIQUOR AMNII. 

Stiffening the linen. Not stiffening, or only a little. 

Mucus, thick. Liquid, not stringy. 

Sometimes sangninolent. Of normal color, or tinted by the meco- 

nium, or again reddish, red, or deep red 
(maceration). 

Beginning slow ; progressive and contin- Beginning sudden, flowing in jets and 

uous flow. intermittent. 

It may occur that the liquor amnii has actually escaped, and yet 
in digital examination one may still feel a bag of waters more or 
less fiUed with liquid. There exist in this case three causes of error. 
The first is the existence of an amnio-chorial sac (Fig. 235). Now 
if this sac exists in front of the foetal part it may be ruptured by the 
finger or spontaneously. The liquor amnii flows away and yet on 
examination there is met (Fig. 236) the intact amnion. In the 
second place, the rupture may have been complete, but the cervix 
retracting after the flow covers the opening in the membranes 
(Fig. 237). In the third place, the rupture of the membranes, com- 
plete, while remaining outside, the uterine orifice is obstructed by 
the approach of the foetal part, which prevents the ulterior flow of 
liquid (Fig. ^8), and again to touch there appears a bag of waters. 

3. Digital examination. — The diagnosis of the integrity of the bag 
of waters is really difficult only in presentations of the vertex, for 



192 



Accouchement. — Phenomena of the Appendages, 



in the other presentations the volume of the sac and the ineqnahties 
of the fcetal part scarcely permit hesitation. An experienced finger 
can sometimes recognize the hair of the fcetus and diagnosticate 
the absence of rupture. During contraction the sac becomes smooth 
and tense. The foetal scalps on the contrary, becomes wrinkled. 



Amniorj 




Fig. 235. — Chorio-amniotic sac. 

By Uplifting the foetal head in the interval between contractions, if 
a llow of the liquor amnii is observed, there is evident proof of the 
rupture of the ovum. Finally in some cases the speculum has 
been introduced, but this mode of investigation is little used. The 
persistence with which I have sought to establish the diagnosis of 
the rupture, or of the integrity of the bag of waters is not superflu- 
ous, for the hydrocephalic head has been perforated at the bregma 
in the belief that the operator was puncturing the membranes. 

Foetus. 
/ Amnion. 

Chorion. 
Uterus. 




^^W 



Fig. 236. 



Fig. 237. 



Fig. 23S. 

R.upture ef chorion, with Rupture of the membrane above Opening of the rupture, ob- 

amnion intact. the uterine orifice. tructed by the approach of the 

foetal part. 

The elements of prognosis that can be draw^n from the bag of 
waters depend upon its volume and upon the period of rupture. A 
flat bag of waters is a favorable augury ; projecting, it predicts dys- 
tocia. All things being equal, the later the rupture of the bag of 
waters the better is the prognosis for the mother and for the child. 
The rule should be to leave the rupture to nature. But if, to follow 



Accouchement. — Phenomena of the Appendages. 19B 

some special indication (placenta prEevia, hydramnios, special 
rigidity of the membranes), artificial rupture becomes necessary, 
the membranes may be opened with the finger nail, which sometimes 
presents difficulties, or with a carefully disinfected instrument 
(Fig. 239). If the bag of waters is large, the rupture should be 
made in the interval of the contractions and the hand should 
moderate the flow of liquid by closing the vulva, as a too violent 
escape favors the procidence of a limb or of the cord. 



Fig. 239. — Membrane perforater of whalebone, with ivory point. 

B. The shoiv. — The ovuline membranes, when they are no longer 
reinforced by the uterine wall, are-easily permeable for the liquor 
amnii, especially when the intra-ovuline pressure is augmented by 
the contractions of labor. Thus when accouchement commences, 
in proportion as dilatation of the cervix proceeds, the liquor amnii 
filtering through the membranes escapes along the vagina and from 
the vulva mixing with the mucus in its passage. The mixture of 
liquids constitutes "the show," which is, then, part ovuline and 
part maternal. The show is glutinous, gelatinous, due to the 
mixture with the cervical mucus and to the secretion of the cervical 
glands. This consistency favors the passage of the foetus through 
the parturient canal. In general the show is of a citron color, 
sometimes streaked with blood. Its appearance is an indication of 
the onset of accouchement. With a dry vagina one can be sure, 
save in a pathological state, that labor has not commenced. 



194 Mechanism of Accouchement, — Foetal Phenomena. 



CHAPTER X. 



MECHANISM OF ACCOUCHEMENT.— FCETAL 

PHENOMENA. 

Whatever the presentation may be, except that of the abdomen 
where accouchement is impossible, the exit of the foetus takes place 
in six stages : 

First stage — diminution. 

Second stage — engagement. 

Third stage — internal rotation. 

Fourth stage — disengagement of the first ovoid. 

Fifth stage — external rotation. 

Sixth stage — disengagement of the second ovoid. 

We shall examine for each presentation the details of each of 
these stages. 

Presentation of the Vertex. — I shall take as the type the 
vertex presentation in L I A, the most frequent position, and I 
shall speak later of the mechanism in the other positions. 

1. Diminution. — The diminution of the head is made by moulding 
and by inclination of the dystocic diameters (flexion and lateral in- 
clination). The moulding, resulting in the deformation of the head 
to be studied under plastic phenomena, is brought about by the 
over-lapping of the bones or by their depression. This variety of 
diminution is only of small importance in presentations of the 
vertex. The inclination of the dystocic diameters, on the contrary, 
takes a considerable part, it occurs by flexion and lateral inclination. 

Flexion, by directing the chin towards the thorax, approaches to 
the genital axis the occipito-mental diameter (IQj), the longest of 
the head. A moderate flexion substitutes the occipito-frontal 
diameter (11^) for the occipito-mental and a very marked flexion, 
the suboccipito-bregmatic (9^) for the occipito-mental (Figs. 240, 
241 and 242). By each of these degrees of flexion there is gained 
two centimetres ; the difference in the circumference belonging to 
each of these diameters is relatively much more important. The 
flexion becomes more and more marked in proportion as the head 
descends into the bony pelvis. This flexion is the normal attitude 
of the head in relation to the trunk and the pressure of the vertebral 
column during the uterine contraction only exaggerates it. Flexion 
is appreciated in digital examination by the relative height of the 
bregma and lambda. Easy access of the bregma indicates want of 



Mechanism of Accouchement. — Foetcil Phenomena. 



195 



flexion. In proportion as the lambda approaches the center of the 
parturient canal the head is flexed. 

The lateral inclination favors the passage of the transverse 
diameters of the head, in particular of the biparietal. It occurs 
around one of the antero-posterior diameters of the head as a pivot 
while flexion takes place around a transverse diameter passing in 
the vicinity of the occipital foramen. With regard to lateral incli- 
nation it is necessary to understand two terms, cynclitism and asyn- 
clitism. x\ synclitic head is that where the two parietal protu- 
berances are found in the same pelvic plane, at the superior or the 
median straits, or at any region of the excavation. An asynclitic 
head is that where the two parietal protuberances are on different 
planes. Synclitism maintains the sagittal suture in the center of 
the pelvis. Asynclism inclines it to one side. Synclitism is un- 
favorable to engagement of the transverse diameters of the head 
and asynclitism is favorable. 




Fig. 240. 

Presentation of the occipito- 
mental diameter, 133^ 
centimetres. 



Fig. 241. 

Presentation of the occipito- 
frontal diameter, 11% 
centimetres. 



Fig. 242. 

Presentation of the suboccipito- 
bregmatic, 9^ centimetres. 



Now does the head, in its pelvic passage, descend by synclitism 
or by asynclitism ? According to Duncan, whose opinion seems to 
me to be correct, the head is synclitic at the superior strait and in 
the superior part of the excavation, asynclitic in the inferior part 
of the excavation and at the inferior strait. 

2. Engagement is the descent of the foetal part from the superior 
to the median strait, the same as disengagement is its passage from 
the median strait to the \T.ilvar orifice. Engagement of the vertex 
occurs usually during the last three months in the primiparae. In 
the multiparae it is more capricious but usually takes place fifteen 
days before accouchement, sometimes sooner, sometimes later, at 



196 Mechanism of Accouchement. — Foetal Phenomena. 

the moment of labor or even only after complete dilatation. What 
has been said on the epoch of engagement supposes the absence of 
all causes of dystocia. 

Engagement during pregnancy takes place under a double 
influence — the influence of the tonicity, the contractility of the ab- 
dominal wall and the influence of utero-pelvic muscles (fibres of the 
broad ligaments, of the utero-sacral ligaments and of round lig- 
aments). During labor, after complete dilatation, the action of 
uterine contraction is added to the preceding to produce engagement. 

The engagement is usually permanent, that is, once produced 
it persists to the end of pregnancy. However, intermittent en- 
gagements have been noted, the foetal part ascends after a mo- 
mentary descent under the influence of the utero-pelvic muscles. 

Engagement is defined by the region of the pelvis where is found, 
not the most inclined part of the head, but the largest part repre- 
sented by the biparietal diameter. We say then : 

Head at the superior strait ; 

Head in the superior or inferior part of the excavation ; 

Head at the median strait ; 
when the biparietal diameter is at the superior strait, in the 
superior or inferior portion of the excavation, or at the inferior strait. 

3. Internal rotation. — The head in its descent accommodates itself, 
to the dimensions of the parturient canal and thus is placed : 

Transverse, at the superior strait. 
ObUque, in the excavation. 
Direct, at the median strait. 

The rule is that the occiput turns forward, the exception, as we 
shall study under anomalies, is backward rotation ; so that at the 
median strait the head is generally found in the occipito-pubic 
position. There have been long discussions as to the reason why 
the occiput, placed transversely at the superior strait, accomplishes in 
descent, its evolution forward rather than backward. The reason is 
probably the curve of the parturient canal, as its axis describes an 
anterior concavity in such a way that the lowest point of the head 
is naturally directed forward to follow the shortest path outward. 

4. Disengagement. — The disengagement begins at the median 
strait and terminates at the vulva. The head escapes from the 
muscular pelvis by a movement of extension. Engagement is char- 
acterized by flexion of the head and passage through the bony 
pelvis; disengagement is characterized by extension and passage 
through the muscular pehds (Fig. 243). 

The head, pushed by utero-abdominal contraction, opens, de- 
presses and hollows out the perinseum. This structure pushing in 
the opposite direction, there result two opposed forces which direct 
the head toward the vulvar orifices. In this movement of exit the 



Mechanism of Accouchement.— Foetal Phenomena. 



197 



head is so placed that the occipito-cervical groove comes under the 
symphysis pubis and from this movement, obeying the action of 
the perinaeum, it accomplishes around tliis groove a hinge movement 
which brings successively to the vulva the suboccipito-bregmatic, 
the suboccipito-frontal and the suboccipito-mental diameters, in 
such a manner that there appear in turn at the perinaeal fourchette 
the nose, the mouth, and the chin. As soon as disengagement is 
terminated, the head, no longer supported by the perinaeum, falls 
in flexion. 




Fig. 243. — L O I T then L O I A. Normal engagement 
and disengagement in O P (Schultze). 

5. External rotation. — From the utero-abdominal contraction, 
which follows disengagement, the head undergoes a movement of 
external rotation, w^hich directs the occiput to the left (we are sup- 
posing a L 01 A). This external rotation of the head is only the 
external manifestation of the internal rotation of the shoulders, 
wdiich, placed transversely at the superior strait, turns like the 
head in descending, being placed first obliquely, then in the coccy- 
pubic diameter. 

6. Disengagement of the trunk. — Pushed by the utero-abdominal 
contraction the cormic ovoid is disengaged little by little at the 
vulva, where appear successively the throax, the abdomen, and the 
breech. 

Thorax. — The most difficult part of the thorax to deliver is the 
bisacromial diameter. Classic authors admit that the anterior 



198 Mechanism of Accouchement, — Foetal Phenomena. 

shoulder first appears and is partially disengaged under the pubis, 
then undergoes a movement of arrest, during which the posterior 
shoulder, after having passed over the vaginal surface of the peri- 
ngeum, is disengaged in turn ; the anterior shoulder then terminates 
its exit. 

This mechanism is, in fact, observed quite often, but I believe it 
to be pathological and due to the action of the weight of the head 
which thus drags the anterior shoulder out before the time for its 
normal exit. The normal mechanism of the exit of the shoulder is, 
according to my observation, the following: While the anterior 
shoulder is arrested and hidden behind the symphysis pubis, the 
posterior shoulder is first disengaged from the vulva and after its 
exit the anterior shoulder is disengaged in turn. This mechanism 
only takes place when the head is sufficiently sustained to avoid the 
pernicious influence of its weight. 

Abdomen. — The abdomen, a soft and impressible region, is dis- 
engaged without difficulty. During its exit the spine ascends slightly 
toward the pubis, the trunk undergoing a slight degree of rotation. 

Breech, — The maternal organs, so largely opened by the successive 
disengagements, allows the foetal breech to escape easily, sometimes 
abruptly, one hip in front, the other behind, as in the case of the 
shoulders. The anterior is usually disengaged a little before the 
posterior, but this mode depends upon the direction given the trunk 
of the foetus and is of little importance. 

The mechanism in each position. — I have taken as the type, in the 
description of the mechanism, L 1 A ; a few lines will be sufficient 
to complete what is necessary with regard to the other positions. 

E 1 A. — The internal rotation of the head follows the same as 
in L 1 A, the occiput under the pubes ; but the external rotation 
occurs in such a way that the occiput turns toward the right side, 
while it was directed toward the left in L 1 A. 

In a general way we can say that, in all the positions, the occiput 
in the fifth stage returns to the side where it is found in the interior 
of the genital organs. 

L 1 P. — The interesting point in the mechanism is here in the 
third stage for, the same as in the previous corresponding position, 
the occiput turns forward to be placed under the symphysis pubis. 
The occiput turns forward because the head, placed in the occipito- 
pubic position, is much better adapted to the genital canal than the 
occipito-sacral. The last three stages present no peculiarity. The 
external rotation of the occiput is made to the left as in L 1 A. 

R 1 P. — The considerations are the same as for the preceding 
position. Internal rotation of the occiput forward. External rotation 
of the occiput to the right. 

I shall not speak of the transverse positions, as they are converted 
into the oblique in the excavation, nor of iiie direct P, C, which 



Mechanism of Accouchement. — Foetal Phenomena. 



199 



scarcely exist except at the median strait and simply represent one 
of the moments of the mechanism of the delivery. 

Irregularities of the mechanism. — Irregularities of the mechanism 
may present in each of the stages of accouchement : 

1. Diminution. — The cephalic moulding will be interfered with 
when ossification is too much advanced. When flexion of the head 
is insufficient, a presentation of the brow or even of the face may 
arise. Lateral inclination also presents variations of secondary 
importance, and which cause, especially in the pathological pelvis, 
inclined presentations. 

2. Engagement. — In multiparous women, whose soft tissues are 
very supple, the same utero- abdominal contraction sometimes pro- 
duces both engagement and disengagement, bringing the head from 
the superior strait to the vulvar orifice. 




Fig. 244. — R O I T then R O I P. Abnormal disengagement 
of the head in O S (Schultze). 

3. Internal rotation. — The movement of rotation may occur too 
soon or too late, for example, when the occiput only turns forward 
when the head arrives in the vicinity of the vulva. This retardation 
is frequent when the foetus is small or the pelvis very large. The 
principal anomaly of this stage of accouchement is rotation of the 
occiput backward. In the occipito-posterior position, right or left, 
and exceptionally in the anterior, the occiput may turn backward 
and the head thus be placed in the occipito-sacral position. The 
exit of the head then takes place as indicated in Fig. 244. The 
occiput passes over the posterior vaginal wall, the head is flexed in 



200 Mechanism of Accouchement. — Foetal Phenomena. 

proportion as it advances. The lambda and the contiguous part of 
the parietal bones are first disengaged from the vulva and the head 
is extended. When the occipito-cervical groove arrives at the 
fourchette, there appear successively at the superior portion of the 
Yulva, the bregma, the forehead, the nose and finally the chin. 
There is a hinge movement analogous to the occipito-pubic, but 
here it is produced around the fourchette. 

4. Disengagement of the head. — The rule is the occipito-pubic and 
I only recall the occipito-sacral wliich we have just discussed. A 
simple mention of excess of slowness or of rapidity during disen- 
gagement is sufficient. The first exposes the life of the foetus, the 
second, the integrity of the maternal perinaeum. 

5. External rotation. — This rotation may not occur, the shoulders 
being expelled from the vulva transversely, or incomplete, the 
shoulders disengaging obliquely. Eotation may occur in an opposite 
direction. This anomaly is due to an excess of rotation of the 
shoulders during the disengagement of the head. 

6. Disengagement of the trunk, — We have seen the anomalies of 
disengagement of the shoulders. The irregularities of the exits of 
the abdomen and of the breech simply depend upon the situation 
of the vertebral column. Their importance is secondary. 

Presentation of the face. — I shall take as a type L M I A. 

1. Diminution. — Moulding, extension and lateral inclination. The 
moulding is slight with regard to the face but it is produced on the 
vault of the cranium. Extension places the axis of the cephalic 
ovoid parallel to that of the parturient canal. Lateral inclination 
occurs with regard to the bimalar diameter. 

2. Engagement. — The engagement, that is, the descent from the 
superior to the median strait, is only observed during labor and 
usually at an advanced period of labor. In proportion as it occurs 
extension is complete ; the chin approaches the center of the par- 
turient canal, and the lambda the vertebral column. The height 
of the head in the pelvis is generally designated by that of the bi- 
malar diameter. 

3. Internal rotation. — This movement directs the chin forward 
under the symphysis pubis. 

4. Disengagement of the head. — The head, during the fourth stage 
traverses all that part of the genital canal comprised between the 
median strait and the vulva. This disengagement is made by a 
movement of progressive flexion. The chin arrives under the 
pubic symphysis, which is exactly applied in the mento-cervical 
groove ; around this the head executes a hinge movement and there 
successively appears, in front of the perin?eal fourchette, the fore- 
head, the bregma, and finally the occiput. The expelled head falls 
backward. 



Mechanism of Accouchement. — Fcetal Phenomena. 



201 



5. External rotation. — The chin turns to the side to which it was 
priDaarily directed. 

6. The disengagement of the trunk is subject to the same consider- 
ations as for the vertex presentations. 

The mechanism in each position. — As for the vertex only the oblique 
position will be in question here. 

L M I A has been taken as the type and described already. 

EMI A. — The internal rotation turns the chin forward, and the 
external turns the cliin toward the right thigh. 

L M I P. — The internal rotation brings the chin forward and the 
external carries it toward the left thigh. 

EMI P. — Internal rotation of the chin forward, and external 
toward the right thigh. 




Fig 245. — LMIT then LMIA. Normal disengagement ol the head 

in MP (Schultze), 

irregularities of the mechanism, — 1. Diminution. — The extension 
may be insufficient and render engagement difficult. 

2. Engagement. — As much more easy as the extension is more 
marked. More rapid in the mento- anterior than in the posterior. 
Prompt in a large multipara, slow and painful in a primipara. 

3. Internal rotation. — The chin, in place of turning forward, may 
turn backward toward the coccyx. This becomes, as we shall see, 
in disengagement, a grave cause of dystocia. 

4. Disengagement of the head. — When the rotation of the chin takes 
place backward, disengagement cannot take place. Accouchement 
in a mento-sacral position is impossible. I deduce from this the 



202 



Mechanism of Accouchement. — Foetal Phenomena. 



following therapeutic conclusion, which should be graven on the 
mind of every physician : Whenever, in a presentation of the face, 
the chin is turned backward, it is necessary to bring it forward ; 
without this, even with the aid of forceps, accouchement is impossible. 
Why tliis impossibility ? The head, in a face presentation, may be 
divided into three zones (Fig. 246) . The first is exclusively cephalic. 




Fig. 246. — The three cephalic zones of lace presentation. 

The second comprises the head and the neck, and the third is com- 
posed of the head and thorax, with the dependent shoulders. Now 
the first two zones can penetrate without difficulty into the exca- 
vation, but the third is too large in the child at term to pass the 
superior strait. When the chin is turned forward it can be dis- 
engaged under the pubic symphysis without the necessity of the en- 
gagement of the third zone ; but when it is turned backward, the 
disengagement of the chin in front of the fourchette is impossible 
without the engagement of the third zone. 

Let us retain this impossibility as the rule, in a practical point of 
view, though recognizing that there exist some exceptions. Mme. 
Lachapelle has observed disengagement in a mento-transverse po- 
sition and Smellie has even seen it in the mento- sacral. 

5 and 6. External rotation and disengagement of the trunk present 
the same anomalies as in vertex presentations. 

Presentation of the brow. — I shall take as a type EMIT. 

1. Diminution, — In ]3resentation of the brow there can be no 
question of flexion or of extension, for flexion causes transformation 
into vertex, and extension into face presentation. The head is 
diminished solely by moulding. The result of this is a deformation 
characteristic of this part of the body (see plastic phenomena). 



Mechanism of Accouchement. — Foetal Phenomena. 



203 



2. Engagement. — The head remains usually a long time at the 
superior strait and engages still later than in presentation of the 
face. The head descends slowly and with difficulty. The height 
of the head is designated hy that of the frontal protuberances. 




Fig. 247. — Brow presentation in R M I T. 

3, Internal rotation. — As in the other presentations of the cephalic 
ovoid the head is placed transversely at the superior strait, obliquely 
in the excavation, and direct at the median strait. The chin in its 
descent usually turns forward ; exceptionally it turns backward. 




Fig. 248. — Disengagement of the head in brow presentation : mento-pubic. 

4. Disengagement of the head. 

a. Mento-pubic. — The head descends little by little, depressing and 
opening the pelvic floor. The bregma always remains in the center 
of the parturient canal or near it. The foetal part finally arrives at 
the vulva and escapes by the mechanism represented in Fig. 248. 

h. Mcnto-sacral. — The head having passed the median strait 



204 



Mechanism of Accouchement, — Foetal Phe^iomena. 



continues its descent. The occiput strikes against the symphysis 
pubis and a swinging movement follows which carries the chin out- 
ward first. The occiput makes its exit last (Fig. 249). 




Fig. 249. — Disengagement of the head in brow presentation: mento-sacral. 



5 and 6. External rotation and disengagement of the trunk occur 
exactly as in presentation of the vertex. 

Meclianism in each position. — I have taken as the type for de- 
scription a E M I T at the superior strait, and I have shown the 
mechanism according as the chin turns forward (E M I A, M P) or 
backward (E M I A, P S). The same considerations apply to L M 
I T according as the chin turns forward (L M I A) or backward 
(L M I P) ; new descriptions are useless. 




Fig. 250. — Disengagement of the cephalic ovoid in vertex presentation. 

Resume. — All authors, who have described presentation of the 
forehead, have endeavored to prove the analogy between the mode 
of exit in presentations of the brow and of the vertex. I shall not 
follow this demonstration. In place of seeking the analogy, I shall 
point out the differences. Presentations of the vertex and of the 
face are, as well as their mechanism, normal, physiological. The 
cephalic ovoid presents by its large extremity (Fig. 250) or by its 
small extremity (Fig. 251), which descends first in the parturient 
canal and escapes first at the vulva, making easy exit by a swinging 
movement of the remainder of the ovoid. It is otherwise in ac- 
couchement by the brow. The foetal part, retained at the superior 
strait, pushed in a vicious direction, remains intermediate between 



Mechanism, of Accouchement, — Foetal Phenomena. 



205 



flexion and extension. The head descends in spite of its vicious 
situation, it is deformed and thus badly engaged, badly directed, 
and is obliged to issue from the genital canal by a peculiar mechan- 
ism, not at all comparable to the normal physiological mechanism. 
From this arises numerous difficulties that are frequent sources of 
dystocia. 




Fig. 251. — Disengagement of the cephalic ovoid in face presentation. 

Presentation of the breech. — I recall in Fig. 252 the four 
varieties of presentation of the breech: Complete; incomplete; 
variety of the buttock ; of the knees ; of the feet. 

I shall take as a type a presentation of the complete breech in 
L SI A. 



Complete 
breech. 



Incomplete. Variety 
of the buttocks. 



Incomplete, Knee 
variety. 



Incomplete. Foot 
variety. 







Fig. 252. — Varieties of breech presentation. 

1. Diminution. — The diminution may be compared in spite of 
important differences to the molding of the head in vertex presen- 
tations. The breech undergoes during its descent movements of 
flexion and extension (bitrochanteric axis) or of lateral inclination 
(sacro-pubic axis), analogous to the movements of the head but of 
less importance. It is sufficient to know that the buttocks are 
synclitic at the superior strait and asynclitic at the inferior strait, 
the anterior being the lower. 

2. Engagement. — The engagement is the descent of the breech 
from the superior strait to the median. When the breech is com- 
plete engagement takes place only during labor and even at an 
advanced period of labor, in general at complete dilatation. The 
height of the breech will be indicated by that of the bitrochanteric 
diameter. 



206 



Mechanism of Accouchement. — Foetal Phenomena. 



3. Internal rotation. — The bitroclianteric diameter, the most volu- 
minous of the pelvic extremity, rules the movement of rotation. In 
spite of its predominant dimensions the bitroclianteric diameter is 
not placed transversely at the superior strait, but obliquely. The 
cause is in part the back, in part the smaller members, which are 
pushed aside by the projection of the vertebral column and thus 
impede the transverse accommodation of this diameter. The 
bitrochanteric diameter, oblique at the superior strait, remains 
oblique in the excavation, and is placed antero-posteriorly at the 
median strait. It is the trochanter nearest to the pubes (the left 
in L S I A) which turns forward, 

4. Disengagement of the trunk. — The breech advances little by little. 
The trunk undergoes a lateral inflexion (Fig. 253) analogous to 
extension for the vertex. The anterior thigh escapes first from the 
vulva, then the posterior. Upon the arrival of the abdomen, the 
trunk undergoes a very slight movement of rotation which inclines 
the vertebral column a little forward. This movement is soon 
corrected by the descent of the shoulders, wliich are placed in the 
antero-posterior direction. The arms are against the trunk (a 
contrary condition is pathological), the elbow appears first, then the 
shoulder, the anterior being disengaged first, and then the posterior 
(Fig. 254). 




Fig. 253. — Lateral inflexion of the trunk in accouchement 
by the breech (Hodge). 

5. External rotation. — This movement will be comprehended if we 
observe a child attempting to pass between two bars of a gate. It 
engages first the head, the face looking upward, then, for the trunk, 
one shoulder is put forward, the other backward, the body passes 
easily now if the space is sufficient. The child has unconsciously 
accomplished the movement of rotation, which permits the succes- 
sive adaptaion of the head and trunk to the space through which they 
must pass. External rotation brings the vertebral column forward 



Mechanism of Accouchement. — Foetal Phenomena, 



207 



so that the head is placed in the occipito-pubic position. Whether 
first to last, then, the head becomes occipito-pubic in issuing from 
the genital organs. 

6. Disengagement of the head. — The head, generally aided by the 
accoucheur, is disengaged by a swinging movement, or by a hinge 
movement around the pubes, analogous to that of the vertex pre- 
sensation, but the head being turned in the opposite direction there 
successively escape from the \Tilva, at the fourchette, the chin, the 
mouth, the nose, the eyes, and the forehead ; after the passage of 
the frontal protuberances the head escapes brusquely. 




Fig, 254. — Successive disengagement of the trunk (variety of the buttocks is here 
represented; disengagement is the same, with complete breech). 



Mechanism in each position and in each variety of presentation. — 
Position (complete breech). — L S I A has been taken as the type 
and described above. 

ESI A. — The right buttock turns forward from left to right to be 
placed under the pubes. The rotation of the occiput is always made 
under the symphysis and disengagement is occipito-pubic. 

LSI P. — The left buttock turns forward and from left to right. 

E S I P. —The right thigh turns forward and from right to left. 

Varieties of presentation. — The complete breech has been taken as 
the type of the mechanism. All that has been said applies to this 
variety. 

Incomplete breech, variety of the buttocks. — The engagement in tliis 
variety often occurs during pregnancy. Tliis precocity is due to 
the relative diminution of the foetal pehds by the extension of the 



208 Mechanism of Accouchement. — Foetal Phenomena. 

lower limbs. The different stages are executed as in presentation 
of the complete breech, with the difference that the extention of the 
impeding the movement of lateral flexion, 
lower limbs renders disengagement of the trunk more difficult by 

Incomplete hreech, variety of the knees and feet. — These varieties are 
only constituted at the moment of accouchement ; they are second- 
ary. The engagement and the disengagement of the trunk are more 
rapid, on account of the diminution of the breech. The exit of the 
head is relatively more difficult than in the other varieties because 
the dilatation of the maternal parts has been less complete. The 
first parts which appear at the vulva are naturally, according to the 
variety, the feet or the knees. 

Irregularities of the mechanism — 1. Diminution may be difficult on 
account of the spreading apart of the lower limbs. 

2. Engagement only occurs at the superior strait when the breech 
presents in the oblique position. In the sacro-pubic or sacral the 
presence of the lower limbs renders this difficult. In the sacro- 
transverse, the bitrochanteric diameter finds difficulty in passing the 
promonto-pubic. 

3. Internal rotation. — The internal rotation may be incomplete or 
exaggerated and an oblique disengagement results. If an anomally 
of rotation places the bitrochanteric diameter transversely, disen- 
gagement is made in this situation. 

Disengagement of the trunk. — Besides the irregularities which have 
been in question, the arms may be uplifted in the attitude of diving. 
This complication is the result of tractions on the trunk and is not 
generally observed when the accouchement has been left to the 
forces of nature alone. 




Fig. 255. — Head last disengaging in occipito-sacral, by a posterior swinging 
movement (disengagement back to back). 

5. External rotation. — The occiput, in place of turning forward, 
may remain transverse or even directed backward. Serious diffi- 
culties of disengagement result from this. 

6. Disengagement of the head. — Occiput transverse. — The head 
escapes somewhat as in occipito-pubic, only a hinge movement takes 



Mechanism of Accouchement. — Foetal Phenomena. 209 

place around one of the ischio-pubic rami, and all the elements of 
the face successively appear at an opposite point of the vulva. 




Fig, 256. — Head last disengaging in occipito-sacral, by an anterior swinging 
movement (disengagement abdomen to abdomen). 

Occiput posterior. — The disengagement is executed in two ways : 
a. By a movement of posterior swinging (Fig. 255) — a hinge move- 
ment is made around the fourchette and disengagement back to 
back occurs, h. By a movement of anterior swinging (Fig. 256) — the 
chin hooks behind the symphysis pubis, the head is progressively 
flexed, the occiput, turned backward, arrives at the vulva — the dis- 
engagement is abdomen to abdomen. 




Fjg. 257. — Presentation of the thorax, a, transformation into vertex; 
b, transformation into breech. 

Presentation of the thorax, — In the different presentations 
that we have already studied, the accouchement may terminate in 
two ways : 



210 



Mechanism of Accouchement. — Foetal Phenomena. 



1. By transformation of one presentation into another, vertex into 
brow and into face, breech into vertex, etc., there is produced a 
veritable mutation. 

2. By a mechanism in six successive stages. 



/^ 






Figs. 258 to 261. — Spontaneous evolution. Different attitudes of the foetus during 
the successive disengagement of the trunk (Spiegelberg). 

In presentation of the thorax, the accouchement, when it takes 
place, is terminated : 1. By transformation of the presentation, 
called spontaneous version. 2. By a mechanism analogous to that of 
the other presentations, here designated as spontaneous evolution. 

Spontaneous version and evolution are terms usually reserved 
for presentations of the shoulder, but they imply no special character. 
The only peculiarity of presentations of the thorax is, that, in the 
usual conditions, they do not terminate in spontaneous accouche- 
ment. It is always necessary to interfere when the foetus presents 
by the thorax. Spontaneous version and evolution should, then, be 



Mechanism of Accouchement. — Foetal Phenomena. 



211 



considered as exceptions, that we should know, nevertheless, as they 
confirm the general laws of the mechanism of accouchement. Their 
interest is consequently more theoretical than practical. 




Fig. 262. — Spontaneous evolution. Successive disengagement of the trunk. 




Fig. 263. — Schema of disengagement of the trunk in spontaneous evolution. 

1. Spontaneous version (or mutation of the presentation). — Under 
the influence of uterine contraction, and before engagement of the 
foetal part, the thorax is seen to draw away from the superior strait 



212 



Mechanism of Accouchement. — Foetal Phenomena. 



and be replaced at that point by the head or the breech. The pre- 
sentation of the thorax is then transformed in the first case into a 
vertex presentation, spontaneous cephalic version; in the second 
case into a breech presentation, spontaneous pelvic version. Though 
this change is easier during integrity of the bag of waters it may 
take place after its rupture. The subsequent accouchement of the 
breech or the head follows the usual rules. 




Fig. 264. — Expulsion of the foetus folded in two (conduplicato 
corpore) (Kleimvachter). 

2. Spontaneous evolution {or normal mechanism of the accouche- 
ment). — The back and the sternum constitute such rare varieties of 
presentations of the thorax that they may be neglected in the point 
of view of spontaneous evolution, so it is only the presentation of 
the shoulder (right or left) that I shall discuss here. 

I shall take as the type a presentation of the right shoulder in 
BAIT. 

1. Diminution. — The diminution is made in proportion to the en- 
gagement. The adherence of the upper limb to the trunk becomes 
more and more intimate (unless it is drawn down and the head is 
at the vulva) and the thorax and the abdomen are successively 
molded to traverse the parturient canal. 



Mechanism of Accouchement. — Foetal Phenomena. 213 

2. Engagement. — The shoulder, which forms the culminating part 
of the presentation, descends by following very nearly the axis of 
the parturient canal. The shoulder first, then the thorax and neck 
folded together, advance progressively and with difficulty. This 
movement of descent is arrested at the moment when the head 
arrives in contact mth the upper part of the pubes. 

3. Internal rotation. — As in all other presentations, the foetal part, 
transverse at the superior strait, is obliquely placed in the exca- 
vation, and antero-posteriorly at the median strait. The head is 
placed forward in such a way that the neck measures the height of 
ihe pubes. The trunk is directed backward. This situation of the 
foetus is indispensable for disengagement. 

4. Disengagement of the trunk. — The fourth stage is the most interest- 
ing and at the same time the most difficult part of spontaneous 
evolution. The foetus first becomes indented (Fig. 258), the inden- 
tation is accentuated (Fig. 259), the foetus is soon folded on itself 
(Fig. 260), and finally the breech continuing to descend, while the 
liead remains immobile, the exit of the trunk is complete (Fig. 261). 

5. 6. — External rotation and disengagement of the head take place 
identically as in presentation of the breech. 

Mechanism in each variety of presentation and of position. — What- 
ever may be the variety of the presentation, right or left shoulder, 
and of postion, E i\. I T or L A I T, the mechanism is analogous, 
rotation of the head and neck forward and disengagement by an 
unrolling of the trunk (Figs. 262 and 263). 

Irregularities of mechanism. — The mechanism of spontaneous evo- 
lution being relatively rare, the anomalies are still more rare. A 
single one merits mention, the exit of the foetus folded in two parts 
as in presentation of the abdomen (Fig. 264). 

Spontaneous version, ]permitting the birth of a living child, only 
occurs in about one case out of forty. This is to say that one should 
always interfere in these presentations. We shall see how in an 
subsequent chapter. 

Presentation of the abdomen. — When a child presents by 
ihe abdomen, whatever the variety (lumbar regions, right or left 
flank, umbilicus), spontaneous accouchement at term is impossible. 
However, with particularly supple foetus, already dead some time, 
or before term, the foetus may make an exit bent double (Fig. 264). 
In presentation of the abdomen the indications for interference are 
absolute. 



214 



Influence of Accouchement on Mother and Child, 



CHAPTER XL 



INFLUENCE OF ACCOUCHEMENT ON 
MOTHER AND ON THE CHILD. 



THE 



Influence of accouchement on the mother. — Nervous sys- 
tem. — Thereoften exists a marked state of restlessness and anxiety, 
sometimes a veritable passing delirium and without importance. 
There are frequent cramps in the lower limbs, due to the compres- 
sion of the obdurator nerve and of the great sciatic. 

Calorification. — Elevation of the temperature some tenths of a 
degree, but no fever in the normal state. 

Respiration. — i\.ccelerated, interrupted by cries and complaints. 

Digestion. — Frequent vomiting during labor. It appears that the 
uterine contractions cause those of the stomach. Sometimes labor 
commences by an indigestion. As soon as the pains become intense 
the woman feels a disgust for food and drink, and it is better to 
exclude food, for the ingestion of liquids or solids often causes 
vomiting. 




Fig. 265. — Formation of the sero-sanguineous swelling. 

Influence of accouchement on the child. — The influence 
of the uterine contraction on the foetal circulation has already been 
explained. The most interesting influence on the foetus consist of 
the different deformations that accouchement produces, which have 
been designated as plastic phenomena. These plastic phenomena 
are of two kinds, one causing a deformation of the soft parts and 
producing a sero-sanguineous protuberance, the other addressed to 
the skeleton and characterized by an osseous deformation. 



Influence of Accouchement on Mother and Child. 



215 



1. SerO'Sanguineous protid)erance. — On the foetal part left bare by 
the dilatation of the cervix there is formed, in the subcutaneous 
cellular tissue, asero-sanguineous infiltration (caput succedaneum). 
The skin at thia point presents a color sometimes red, more often 
violaceous and quite clearly circumscribed. This, added to the 
doughiness of the subjacent tissues, permits an easy diagnosis after 
birth. Sometimes there exists congestion of the periosteum and 
also of the pia mater, and of the brain if it relates to the head. 



\ o 







Fig. 266. — Vertex; different sites of the sero-sanguineous swelling according 

to the position. 

The mechanism by which this sero-sanguineous swelling is pro- 
duced is only that of cupping (Fig. 265). The situation of the 
swelling naturally varies with the presentation (Fig. 266). The 
sero-sanguineous swelling has only the inconvenience of deforming 
the foetal region on which it is situated. It disappears in three or 
four days and demands no special treatment. 

2. Osseous deformations of the foetal head caused by the over-laping 
of the bones. The general result of this over-riding is a change in 
the configuration of the head as indicated in the subjoined figures. 





Fig. 267. — Form of the head after ex- Fig. 268. — Form of the head after ex- 
pulsion in left or right occipito-anterior pulsion in left or right occipito-posterior 
vertex presentation (Tarnier). vertex presentation (Tarnierj. 



216 



Influence of Accouchement on Mother and Child. 





Fig. 269. — Form of the head after ex- Fig. 270. — Form of the head after ex- 
pulsion in brow presentation (Tarnier). pulsion in face presentation (Saxinger). 



Promontory. 




Pubes. 



Fig. 271. — Deformation of the head expelled last. 

Causes of accouchement. — We find in the production of 
accouchement two causes, efficient and determinate. 

1. Efficient causes. — The fcetus is essentially passive during ac- 
couchement and the efficient cause of the birth of the child is 
uterine contraction aided by that of the abdomen. There have been 
some cases of spontaneous accouchement observed after the death 
of the mother, testifying simply to the persistence of uterine con- 
traction after the cessation of life. 

2. Determinate causes. — Why does the uterus enter into contraction 
at the end of nine months, the normal term of pregnancy ? The 
foetus, the membranes, and the uterus, have been in turn brought 
forward as causes. 

a. Foetus. — All impediments of foetal physiology have been given 
as determining accouchement. Opinions formerly varied much on 
the source of these obstructions. I cite the principal ones : Dis* 
tension of the intestine by meconium and of the bladder by the 
urine ; insufficiency of circulation by progressive narrowing of the 
foramen ovale ; obstruction to foetal movements by the uterus be 
coming relatively too small. 

It is possible that accouchement may have the fortunate effect of 
affording a remedy for these obstructions, but it cannot be con- 
ceived that they are capable of becoming the determinate cause of 
labor. 



Influence of Accouchement on Mother and Child, 217 

6. Membranes. — At term the degenerated decidua is separated 
from the uterus to qaite a great extent. Thus the OYum forms a 
foreign body in the uterus and produces labor (Simpson). It is 
certain that every foreign body in contact with the internal surface 
of the uterus causes more or less severe contractions, but it is 
difficult to understand why, the separation of the ovum from the 
uterus being progressively made during the last three months and 
the detachment proceeding from the internal orifice toward the 
fundus, labor occurs exactly at the end of nine months and not at a 
more advanced period. Besides in pathological adhesions of the 
membranes labor would never occur. 

c. Uterus. — The derminate cause has been sought, either in the 
circulation of the uterus or in the muscular tissue of the organ. 

Circidation. — Two theories : 

Theory of uterine asphyxia. — Like all the muscles of organic life, 
the uterus is very sensitive to the action of carbonic acid ; now the 
stasis in the last period of pregnancy favors the accumulation of 
this gas, and to this Brown- Sequard attributes the production of 
labor. The principle of this explansrtion is true, but, this local 
asphyxia being progressive, it is difficult to comprehend how it 
becomes, just at normal term, sufficient to produce accouchement. 

Theory of the tenth menstrual epoch. — Every month during preg- 
nancy, at the time corresponding to the menstrual epoch, is produced 
a genital congestion which favors uterine contraction and exposes 
the woman to abortion. Tyler Smith advances the theory that the 
tenth menstrual period becomes the cause of labor. This theory 
cannot be admitted, for often the time of accouchement does not 
coincide with the tenth menstrual period. 

Muscular fibre. — Two theories; 

Theory of maturity of the uterine fibre. — Chaussier believes that 
the uterine fibres attain a maturity which renders them apt to 
contract energetically at the end of nine months. This is pure 
hypothesis. 

Theory of the irritability of the uterine fibres. — Uterine irritability, 
latent during the course of pregnancy when it is only revealed by 
slight contractions, is manifested in all its energy at the term of 
gestation, awakened either by distention of the body of the uterus 
or by that of the cervix. 

a. Distention of the body of the uterus. — This theory sustains that 
the uterus, like the rectum and the bladder, will contract when it is 
distended to the maximum and that accouchement thus takes place 
by a mechanism analogous to defecation and to micturition. Se- 
ductive at first glance, this is not satisfactory on attentive examin- 
ation. For if accouchement took place by a similar mechanism. 



218 Influence of Accouchement on Mother ajicl Child. 

the moment of its defecation might vary, as the periods of mictu- 
rition and defecation vaTy in different women, and take place at the 
seventh, eighth, ninth or tenth month. Besides the same woman 
may be delivered at term of a single foetus or of two, and in the 
second case the uterus is much more distended than in the first. 
Finally in extra-uterine pregnancy a pseudo labor follows at term. 

b. Distention of the cervix. — According to Levret, the cervix becom- 
ing effaced in the latter part of pregnancy, uterine contractions 
follow. But this theory cannot be admitted for often the cervix is 
only effaced during labor. 

In resume, in all the preceding theories, we find influences which 
explain the appearance of labor but none of them explain why labor 
is regularly produced at the end of the ninth month. 

Diagnosis of accouchement. — When a physician is called 
attend to a woman normally pregnant and suffering intermittent 
abdominal pains, he should always seek the solution of the following 
questions : 

I. Is this woman in labor ? 

II. What is the presentation and the position of the foetus ? 

I. Diagnosis of labor. — In a practical point of view it is the immi- 
nence of foetal expulsion that we seek. We wish to know how soon 
the woman will be dehvered and whether to remain or not, to assist 
at the moment of expulsion. Now there is no diagnostic point that 
is more exposed to error than this. An experienced accoucheur 
may decide that the woman will not be delivered soon and yet in an 
hour the child may be born. Again, he may assure the woman that 
she will be delivered in a few hours and yet at the end of twelve or 
twenty-four hours the accouchement has not advanced, and labor 
may even be postponed for two weeks or a month. These inevitable 
errors are due : 

1. To the difficulty of exactly recognizing the beginning of labor. 

2. To the rapidity, sometimes excessive, of the accouchement. 
B. To the arrest and retrocession of labor. 

Labor, according to some, commences with painful uterine con- 
traction, but certain women are delivered without suffering, while 
others suffer all through the last month of pregnancy. According to 
others, who make labor synonymous with the opening of the cervix 
(effacement and dilatation), it begins with effacement of the cervix. 
This is certainly a valuable element, but in which we cannot fully 
confide, for some women have the cervix effaced in latter part of 
pregnancy without being in labor. 

Labor, in fact, is the assemblage of acute modifications which are 
produced in the maternal organism to cause with a brief delay the 
birth of the child. It is necessary not to remove from the term labor 



Influence of Accouchement on Mother and Child. 219 

its signification of approaching expulsion, as without this it loses 
all practical interest and falls into theoretical domain. 

It is important to seek the elements on which we can base our 
diagnosis of labor. They are three in number : 

Painful uterine contraction. 

Opening of the cervix. 

The show. 

Uterine contractions only indicate labor when they are markedly 
painful. It is especially necessary not to confound with them other 
pains (vesical, intestinal, nepliritic, hepatic colic) which may occur 
in the abdomen. 

The opening of the cervix comprises effacement and dilatation of 
the external orifice. Now, when after effacement the dilatation has 
attained two fingers' breadth, or more, the diagnosis of labor is no 
longer doubtful. Two successive examinations with a quarter of 
an hour interval wiU be sufficient to show if the opening is progres- 
sive or stationary. If progressive,. the diagnosis of labor can be 
made; if stationary, the diagnosis should be reserved. When 
several examinations of the cervix reveal no modification, we can 
conclude in cases where the uterine pains are nul or little energetic, 
and where the vagina presents. but little show, the absence or arrest 
of labor. 

The show, the flow of which indicates both the opening of the 
cervix uteri and the energy of the uterine contractions, is also a 
good sign of labor. 

When these three signs are present the diagnosis of labor is easy. 
But one of them may be wanting ; for example, the uterine con- 
traction remaining painless or the cervical dilatation not progres- 
sing. In such cases we can still make a diagnosis of labor when 
the two existing signs are clear and characteristic. Finally two of 
these signs may be wanting, and a single one permit us to establish 
the diagnosis of labor ; for example, the progressive dilatation of the 
cervix with the absence of pain or of the show. We can then say 
a woman is in labor when there is found : 

I. Contractions of the uterus, markedly painful. 

•2. A progressive opening of the cervix (effacement or beginning 
dilatation), or with a cervix effaced and dilated at least to an extent 
equal to two fingers' breadth. 

3. A sufficiently abundant and continued show. 

II. Diagnosis of the presentations and positions. — The diagnosis of 
the presentation and position of the foetus is made with the aid of 
palpation, of auscultation and of digital examination. Interrogation 
and inspection furnish us no knowledge of importance on these 
points. 



220 Influence of Accouchement on Mother and Child. 

We have already seen, apropos of pregnancy, how palpation and 
auscultation may lead to the diagnosis of the foetal presentations 
and positions. We have also seen what information may be fur- 
nished by vaginal touch before the opening of the cervix, there only 
remains to study digital examination after the opening of the cervix» 

Vaginal touch after the opening of the cervix. 

1. Vertex. 

a. Presentation. — Fcetal part, hard, rounded, even. Sutures and 
fontanelles — the lambda is nearer to the genital axis than the 
bregma. In the opposite condition, the presentation is that of the 
brow or tending toward it. 

h. Position. — The position will be indicated by the sagittal suture, 
the lambda indicating the situation of the occiput. 

c. Causes of error. 

1. Vices of ossification. — The accessory fontanelle has only two 
sutures, terminating in it, and will not be confounded with the 
lambda which has three, nor with the bregma which has four. 

2. The asteric fontanelle, in cases of inclination of the head may 
be mistaken for the lambda. The asjteric fontanelle will be recog- 
nized by the projection of the asterion and the vicinity of the ear. 

3. If a sero-sanguineous swelling prevents the perception of the 
details of the head, the ear will be sought and the direction of the 
occiput ascertained by exploring its pavilion. 

4. In cases of cephalic malformation, manual examination will 
permit us to reach the face and even the trunk of the child. 

2. Face, 

a. Presentation. — Special sensations furnished by the mouth, the 
nose and the eyes. 

h. Position. — The exploration of the preceding organs, when the 
chin cannot be reached, allows determination of the position. 

c. Causes of error. 

1. Confusion with the buttocks may take place when the cheeks 
are considerably swollen. Distinction by the presence of the facial 
organs around the groove. 

2. Confusion of the mouth with the anus. — In the mouth are felt 
the maxillary alveoli, the tongue and the fraenum of the tongue. 
From the anus the finger returns soiled with meconium. 

3. Brow. 

a. Presentotio^.— Chaiacters analogous to those of the vertex (but 
with the lambda accessible with difficulty or not at all). The 
orbital arches, the eyes, and even the nose, may be reached. 

h. Position. — After exploration of the bregma and the lambda or 
of the height of the face the situation of the head can be diagnosed. 

c. Causes of error. — The same as for a vertex presentation. 



Influence of Accouchement on Mother and Child. 221 

4. Breech. 

a. Presentation. — Complete breech — buttocks, feet, sacral crest, 
coccyx-, anus, external genital organs. Incomplete breech — same 
characters minus the feet. Variety of the knees — two small cyl- 
inders, constituted by the two segments of the lower limb, meeting 
at an angle. Variety of the feet — only the feet can be felt. Manual 
touch alone allows the breech to be attained. 

b. Position. — Whatever the variety of the presentation, the po- 
sition can be clearly determined only when the anus and the 
coccyx or the sacral crest can be felt. 

c. Causes of error. — I shall not return to those mentioned apropos 
of the face. Knees — confusion with the elbow, differentation by 
exploration of the contiguous parts in difficult cases. Foot — con- 
fusion with a hand, fingers larger than toes, thumb clearly separated 
from the fingers. In the foot, the contiguous malleoli are quite 
different from the wrist. 

5. Thorax. 

a. Presentation. — Characteristic' costal region. 
Dorsal variety — projections of the spinal apophyses. 

Sternal variety — sternal quadrilateral interrupting the costal 
region. 

Shoulder variety — projection of the shoulder and of the acromion, 
scapula on one side, clavicle on the other (the diagnosis of right and 
left shoulder will be made with that of the position). 

b. Position. — In the dorsal and sternal varieties, the position can 
scarcely be recognized except by manual touch or by the aid of pal- 
pation, but most often this diagnosis is to be made in the shoulder 
variety. To recognize the presentation of the shoulder and its po- 
sition we have recourse to three elements, of which two should be 
clearly determined. Presentation of the shoulder is like a triangle, 
of which two angles being known we can determine the third, and 
at the same time all the triangle. 

These three elements are : 

Head.\ T^Back, 




Shoulder. 

When the situation of the back and of the head is known, the 
shoulder which presents and the position of the foetus can be de- 
termined. When the situation of the back and the shoulder which 
presents are known, the situation of the head can be determined. 
W^hen the situation of the head and the shoulder which presents are 
known, the position of the back can be determined. It is evident 
that palpation will be a great help in the determination of these two 
elements. 



222 Influence of Accouchement on Mother and Child, 

c. Causes of error. 

Procidence of a foot may lead to a confusion with a presentation 
of the breech. Attentive exploration will avoid this confusion. 
Procidence of a hand in another presentation than that of the 
shoulder may give rise to doubts only removed by a detailed exami- 
nation. 

6. Abdomen. 

a. Presentation. — Characteristic softness of the abdomen. 

Umbilical variety — insertion of the umbilical cord. 

Variety of the flanks — contiguity of the costal region and of the 
iliac crest. 

Variety of the lumbar regions — resisting part, with the pro- 
jections of the spinal apophyses, dividing the soft tissues. 

h. Position. — The diagnosis will be made in a manner analogous 
to that indicated for the thorax. The situation of the back and 
head will be determined by palpation and manual touch. 

c. Causes of error. — The softness of the abdominal wall may 
create confusion with a thick bag of waters. The insertion of the 
cord and, at need, manual touch will avoid mistakes. 

Duration of accouchement. — The duration of accouchement 
is quite variable ; however, it can, outside of causes of dystocia, be 
fixed at twelve hours in the primipara and at six hours in the multi- 
para. The period of the opening of the cervix occupies about five- 
sixths of this time and the expulsion one-sixth. 

Previous deliveries give information on the rapidity for, all things 
being equal, the duration of accouchement remains proportionately 
equal in the same woman. Heredity also plays an interesting part, 
as the study of certain number of cases permits the formulation of 
the following : The duration of the accouchement is, in the absence 
of all causes of dystocia, analogous to that of the accouchement of 
the mother or of the paternal grandmother, according as the 
physical resemblance of the woman relates to her mother or to her 
father. Accouchement in obese females is generally longer than 
normal. 

The question of the presumable duration of the accouchement is 
one of those so often asked of a physician during labor. The 
responses should be very circumspect, for the duration is exceed- 
ingly variable and errors are frequent. 

Prognosis of accouchement. — The prognosis of accouche- 
ment for the mother and for the child depends upon such a multi- 
tude of conditions that it will be impossible to trace here more than 
a bare outline. 



Influence of Accouchement on Mother and Child. 223 

A. Mother. — The prognosis for the mother depends : 

1. Upon the presentation and the position of the child. The more 
frequent a position, the better is its prognosis. With regard to 
the piesentations of the cephaUc ovoid the anterior positions are 
more favorable than the posterior, on account of greater facility of 
internal rotation. 

2. Upon peculiarities of pregnancy or of accouchement. Twin 
pregnancy ; hydramnios ; viscous insertion of the placenta ; lacer- 
ation of the cervix, perinaeum, etc., all complications, darken the 
prognosis. 

3. The place in which the woman is delivered. Formerly, before 
the antiseptic period, the hospital was a deplorable place for ac- 
couchement. To-day puerperal mortality is less in the hospital 
than in the private houses. 

4. Upon the person who assists at delivery. Numerous compli- 
cations result simply from violation of antisepsis, from ignorance, 
and from too great haste in interventions. 

B. Child. — The prognosis for the child depends : 

1. Upon the presentation and the position. 

a. Foetal mortality according to the different presentations (out- 
side all causes of dystosia, other than that caused by the presen- 
tation). 

CEPHALIC OVOID. CORMIC OVOID. 

1. Vertex ^^-^ 1. Breech y\ 

2. Face 2V 2. Thorax | 

3. Brow .^ 3. Abdomen ? 

For each ovoid the order of increasing gravity is the following : 

Presentation of the large extremity. 
Presentation of the small extremity. 
Presentation of the intermediate part. 

h. Prognosis according to the variety of presentation and of po- 
sition. 

Vertex — The occipito-anterior positions are more grave than the 
anterior. 

Face, Brow — The mento-posterior positions are also more grave 
than the anterior. 

Breech — The incomplete breech, variety of the thighs, is of worse 
prognosis than the other varieties. 

Thorax, Abdomen — The dorso-anterior positions are more favor- 
able, when version is necessary, and the posterior, on the 
contrary when embryotomy is required. 

2. Upon the volume and upon the number of foetuses. The 
greater the volume of the child the more the chances of dystocia 



224 



Management of Accouchement. 



increase. The more foetuses in the uterine cavity, the more unfa- 
vorable becomes the prognosis for each one of them. 

3. Upon the conformation of the woman. 

4. Upon the complications of pregnancy and of accouchement. 

5. Upon the person who assists at delivery as for the mother. 



CHAPTER XII. 



MANAGEMENT OF ACCOUCHEMENT. 

1. Management of accouchement in general. — A. Pre- 

paratorij. — All useless textures should be removed from the partu- 
rient chamber. The room should be heated to 18° C. and maintained 
at that temperature to avoid the chilling to which the woman is 
exposed. 

Folded sheet. 
Impermeable. 
Folded sheet. 
Impermeable. 
Sheet. 
Mattress. 




Fig. 272. — Bed prepared for accouchement. 

In preparing the bed for an expected accouchement there is placed 
over the sheet covering the mattress (Fig. 272) an impermeable cloth 
(oil-cloth or rubber) having the width of the bed and a length of 
about one metre and a half. Above this is a sheet fplded double, 
then another impermeable cloth and, finally, a sheet folded double 
as before. These sheets are fixed to the mattress by safety pins. 
The first portion, including the first impermeable cloth, is to be re- 
moved after deHvery ; the second is to be left during the post-partum. 

A vaginal injector is indispensable. The most simple is the best. 
I use the injector represented by Fig. 273. A bed-pan is equally 
indispensable. 

Absorbent cotton should be used in place of a sponge, and to 
apply to the vulva during the post-partum. 

The armamentarium of the obstetrician should consist of forceps, 



Management of Accouchement. 



225 



uterine sound, needles and sutures, ordinary scissors, two bistouries, 
one pointed the other blunt, six liBemostatic forceps, obstetrical 
stethoscope, a speculum and a hypodermic syringe. It will be better 
to add a bottle of chloroform and one of a solution of ergotine, two 
rolls of iodoform gauze, two vulsela and a dressing forceps. 




Fig. 273. — Vaginal irrigator of nickeled metal. 

B. Management of accouchement. 

Period of dilatation of the cervix. — At the beginning of labor an 
enema should be given to have the rectum empty during the period 
of expulsion. Every three or four hours the vulva should be washed 
and this should be followed by a vaginal injection (bichloride of 
mercury, 1-4000), taking care during the first injection to make as 
complete lavage as possible by rubbing the vaginal and cervical 
walls with the fingers, or better, by using the finger irrigator (Fig. 
274). This genital toilet should be made by the physician for on 
the asepsis of the genital organs depends the normal progress of 
the post-partum. 




Fig. 274. — Finger irrigator. 

The distention of the bladder will be watched, and when mictu- 
rition is impossible catheterism will be necessary. 



226 



Management of Accouchement, 



During this period of dilatation of the cervix the patient may move 
about at will (except in certain special conditions which necessitate 
a horizontal decubitus). 

Period of expulsion. — During the close of the period of dilatation, 
and especially during the period of expulsion, it is important to 
auscultate the sounds of the foetal heart, to be in readiness to in- 
tervene if their exaggerated frequence or their slowness causes fear 
for the life of the child. From the moment of complete dilatation 
the woman should remain in bed, in the position that is agreeable 
to her. 

As soon as the head appears at the vulva (primipara) or in its 
vicinity (multipara), the woman will be placed in the lateral position 
or the dorsal position. The buttocks are raised (Fig. 275) the thighs 
flexed and separated. Two persons give each a hand to the patient 
to afford a support in her efforts. The accoucheur sustains the 
perinaeum and watches the exit of the child, which should be as 
slow as possible. The head, or in a general manner the foetal part, 
should be brought tlirough the vulvar orifice in the interval between 
two contractions. At this moment the patient should be instructed 
not to bear do^vn, in spite of the imperious need she feels, or to 
bear down in the interval of the uterine contractions 




Fig. 275. — Buttocks raised to facilitate expulsion. L, book ; A, sheet wrapped 
round the book and corresponding by its free end with the feet of the woman. 

Generally at the moment the anus dilates the woman feels the 
need of defecation and sometimes demands permission to get up. 
The physician should refuse this, explaining at the same time that 
it is only a false call of nature and the result would be nul. 

Ligature of the cord and delivery of the appendages. — After the birth 
of the child it is necessary to tie and to cut the cord and to proceed 
to the delivery of the after-birth. The management of the latter will 
be considered in the study of the last stage of accouchement; here 
we will simply attend to the ligature of the cord and the care con- 
secutive to delivery. 

To avoid accidents it is better to tie the cord, in spite of its use- 
lessness in many cases. The cord should be tied with an ordinary 
large thread wound two or three times around it. One ligature 
should be placed at four centimetres from the umbilicus and one 
at the maternal vulva. The cord is then cut between these two at 



Management of AccoucJiement. 227 

one centimetre from the ligature next the child. This ligatm-e of 
the cord should be performed after the complete cessation of the 
vascular pulsations (five to ten minutes after delivery). 

Care consecutive to delivery. — Proceed at once to the toilet of the 
woman with a carbolic solution, 1-50. A simple vulvar lavage is 
sufficient in normal cases, and when the care previously mdicated 
has been taken during accouchement. If not, a vaginal injection, 
and an intra-uterine injection, if needed, will be given. Perineor- 
rhaphy is performed if necessary. At this moment it is necessary 
to watch the condition of the uterus by palpation on account of the 
frequency of haemorrhage. The physician should not leave the 
parturient v/oman for an hour or more after delivery and before 
leaving he should be well assured that the uterus is well contracted 
by grasping it through the abdominal wall. 

Management of each position in particular. — A. Presen- 
tation of the vertex. — Internal rotation. — In the case of a posterior 
position the rotation of the occiput may occur late and impede the 
progress of labor. It should be aided when there exist complete 
dilatation and pronounced flexion of the cephalic ovoid, and when 
the vertex is supported by the perinaeum. If one of these conditions 
does not exist it will be well to wait. The internal rotation may be 
aided with the fingers, the vectis, or the forceps. 

Fingers. — Gliding two fingers in front of the sacrum to push the 
posterior parietal protuberance forward, or two fingers behind the 
pubes to push the brow backward. 

Vectis.— The, vectis is not much used at present. This is a mis- 
take, for in some cases, notably the ones now under consideration, 
it is capable of actual service. Slipped in behind the union of the 
occiput and parietal bones it accentuates flexion and causes rotation 
by the pressure it permits from behind forward. 

Forcejys. — The forceps should only be employed when the pre- 
ceding means have failed and when there is no hope of seeing 
spontaneous delivery. In the study of this instrument we shall see 
its application. 

Disengagement of the head. — It is necessary to use care, in aiding 
extension of the head during its exit through the vulva, to have the 
occipito-cervical groove in contact with the lower part of the pubes 
(Figs. 276-277). Without this, disengagement is unfavorable (Figs. 
278-279). 

In cases of uterine inertia, the disengagement of the head will be 
delayed. It will then be aided by the use of the fingers or of the 
forceps. 

Fingers. — When the head is sufficiently advanced in the vulvar 
orifice, two fingers in the rectum can hook down the chin and favor 
cephalic extension. 



228 



Management of Accouchement. 



Forceps. — The employment of the forceps will be justified and 
indicated in the tln*ee following conditions : 

1. Maternal danger. — Syncope; eclampsia; liBemorrhage; ex- 
cessive fatigue ; elevation of temperature to 39'-40^ C. 

2. Foetal danger. — Acceleration or notable retardation of the 
heart sounds. 

3. Arrest of accouchement. — Caused either by uterine inertia or by 
excessive resistance of the perinseum. The application of the 
forceps is authorized when, during the period of expulsion, the head 
has remained two hours at the same point of the parturient canal. 
A compression of the same point of the maternal tissues for more 
than two hours exposes to gangrene and consecutive fistulae. 





Figs. 276 and 277.— Disengagement of the suboccipito diameters (iavorable). 





Figs. 278 and 279, — Disengagement of the occipito diameters (unfavorable). 

Immediately on exit of the head care must be taken to wipe away 
from the child's mouth the mucus w^hich may penetrate into the 
respiratory passages. Finally, the finger takes note if the cord is 
around the neck. If so, it is disengaged by passing it above the 
head or by gliding it over the shoulder, or finally, if it is too tightly 
compressed, by cutting it between two ligatures, or if time presses, 
without any haemostatic precaution. 

Disengagement of the trunk. — The head should be sustained imme- 
diately after its exit. If the disengagement is tardy the women is 
asked to bear down wliile the head is drawn upward to favor a normal 
exit, posterior shoulder first, then the anterior. If this fail, the 



Manaffement of Accouchement, 229 

head is then lowered to disengage the anterior shoulder first. The 
rest of the trunk is delivered without difficulty by drawing slightly 
on the body, one hand still supporting the perinaeum. 

B. Presentation of the face. — Period of dilatation of the cervix. — I 
believe the different means advised for converting a face into a 
vertex are seldom indicated when the face presentation is marked 
or when the head is completely extended. 

Period of expulsion. — The rotation of the chin forward in the mento- 
posterior positions being obligatory, it is necessary to bring it for- 
ward at any price. 

Disengagement. — When the mento-cendcal groove is under the 
pubes the flexion of the head should be favored. The other indi- 
cations are the same as for the vertex. 

C. Presentation of the broiv. — During labor the indications vary 
according to the situation of the head. Before complete dilatation 
effort is made to transform the brow into vertex or face by the aid 
of external manoeuvres, internal, combined, or with the aid of an 
instrument. Transformation into a vertex presentation is preferable 
to that of the face. At complete dilatation the previous methods 
are equally employed but three other methods occur, version, 
forceps and embryotomy. Version causes a transformation of the 
brow into a breech position. Podalic version by internal version 
can be followed by complete extraction or left incomplete. The 
forceps applied at the superior strait may grasp the head with or 
without previous reduction. In cases w^here none of these methods 
has been successful cephalic embryotomy remains. When dila- 
tation has been complete a certain time (the head being still at the 
superior strait) these procedures may still be employed, but as labor 
advances version becomes more difficult. When the foetal head has 
penetrated mto the excavation there is no longer a question of 
version; the forceps alone remains to complete delivery, or if this 
instrument fail embryotomy will be necessary. When the median 
strait has been passed and the head is in the muscular pelvis, the 
soft parts only oppose a relatively slight resistance, which the 
forceps will quickly overcome. 

D. Presentation of the breech. — The management of delivery varies 
according as the breech is incomplete, thigh variety, or presents 
one of the three other varieties. 

1. Breech, complete and incomplete (knees and feet). — The manage- 
ment is the same in these three varieties. 

Period of dilatation of the cervix. — In some cases cephalic version 
may be attempted by external manoeuvres before rupture of the bag 
of waters, and after rupture the same version by mixed manoeuvres. 



230 Management of Accouchement. 

The woman should remain recumbent during the period of dilatation 
of the cervix to avoid^ as much as possible, rupture of the membrane 
and a too sudden escape of liquid. 

Period of expulsion. — Thi'ee points dominate and sum up the con- 
duct of the physician during tliis period: 1. To place the woman 
in the obstetrical position. 2. Never to interfere, except in com- 
plications, during the exit of the cormic ovoid. 3. Always, or 
almost always, to interfere during the exit of the cephalic ovoid. 

a. To place the w^oman in the obstetrical position, that is, across 
the bed, the legs sustained by the assistants, or each foot supported 
on a chair. This position wall be prescribed when the breech 
arrives at the vulva. 

h. Never to interfere, except in complications, during the exit of 
the cormic ovoid. To draw on a limb or foot is so easy and so 
tempting in the desire to assist the w^oman, but it is deplorable 
practice. It is sufficient to sustain the trunk, to avoid dragging on 
the cord and to watch the direction of the back. 

c. Always, or almost always, to interfere during the exit of the 
cephalic ovoid. When the trunk has been expelled, and the head 
still remains in the maternal genital organs, the funicular circu- 
lation is interrupted by the compression of the cord between the 
maternal wall and the foetal part. Thus it is of importance to 
extract the head promptly. This will be done with two fingers in 
the mouth, the other hand grasping the foetal neck. The chin is 
carried backward and the hinge movement is simulated with the 
hands, as in the normal mechanism of delivery of the breech. In 
some cases the forceps will be necessary. Embryotomy will be use- 
ful only in cases of disproportion between the foetus and the partu- 
rient canal. 

2. Incomplete hreech, thigh variety. — What has been said with 
regard to the preceding varieties equally applies here, except that 
there are some new considerations on the subject of extraction of 
the trunk. When the lower limbs are extended the obstetrician 
finds difficulty in the delivery because in extraction there is no 
available part of the foetus to be grasped. To avoid this it has been 
proposed to draw down on both lower limbs by a hand introduced 
into the uterus before engagement, or even after if the foetus can 
still be pushed up. When this is impossible three methods of ex- 
traction remain, the blunt hook, the fillet, and the forceps. 

The blunt hook. — The finger introduced into the fold of the groin 
and curved like a hook may serve for the extraction of the breech. 
It is the best of blunt hooks and less dangerous than the numerous 
instruments of this form that have been advised. 

The fillet consists of a cord passed around one of the tliighs of 
the foetus to serve for traction. Any inoffensive and soft substance 
will answer. It is passed by the aid of the fingers or, better, by 



Management of Accouchement. 



231 



the use of a hook intended for this special purpose (Fig. 280). 
The tractions are made during the utero- abdominal contractions. 

The forcejjs are applied over the trochanters to grasp the bitro- 
chanteric diameter as firmly as possible. 




Fig. 28o.--The fillet. 

E. Presentation of the thorax. — During the period of dilatation of 
the cervix, if the membranes are intact, cephalic version will be at- 
tempted by external manoeuvres, or if the membranes are ruptured, 
this is performed by mixed procedures. 

Period of expulsion. — Immediately after complete dilatation, po- 
dalic version by internal manoeuvres should always be performed, 
no account being taken of the chances of spontaneous evolution 
except in abortion. In cases where this intervention is impossible 
embryotomy is indicated. 

F. Presentation of the abdomen requires the same management as 
that of the thorax, with the difference that if embryotomy becomes 
necessary it is not section of the neck that is made but evisceration. 



232 Accouchement. — Delivery of the Appendages, 



CHAPTER XIII. 



ACCOUCHEMENT.— DELIVERY OF THE 
APPENDAGES. 

Delivery of the foetal appendages may be normal (physiological) 
or abnormal (pathological). These terms define themselves. I shall 
only study here the physiological delivery, the pathological being 
reserved for later discussion. In the point of view of intervention 
delivery is called : 

Spontaneous or natural, when it is left to the forces of nature 
alone ; 

Favored, when, by expression or by traction, the exit of the ap- 
pendages is aided ; 

Artificial, when, to obtain the appendages, it is necessary to 
introduce the hand or instruments into the uterine cavity. 

A. Mechanism. — Delivery takes place in three stages: 

First stage. — Detachment of the appendages. — The placenta, de- 
tached by a mechanism to be studied later, falls on the uterine 
circle which at this moment represents the internal orifice of the 
uterus. 

Second stage. — Uterine expidsion. — The placenta is expelled 
from the uterine cavity into the vagina by passing through the 
portion extending from the uterine circle to the external orifice, 
representing the engagement of the placenta. 

Third stage. — Vaginal expulsion. — The placenta is pushed out of 
the vagina through the vulvar orifice, representing disengagement 
of the placenta. 

First stage. — Detachment of the placenta. — Two theories have 
been advanced to explain this detachment : 

a. Detachment hy effusion of blood (Baudelocque). — The blood 
breaking up the attachments uniting the placenta to the uterus, is 
effused between these two organs, and, its quantity progressively 
increasing, mechanically separates the placenta and the membranes 
from the uterus (Fig. 281). In this theory the uterine muscular 
structure plays an almost passive part. 

h. Muscular theory (Matthews Duncan). — Contrary to the pre- 
ceding theory, the muscular structure here plays the principal 
role; it is the retraction and contraction of the organ, which, 
progressively diminishing the uterine cavity, pushes the placenta 



Accouchement. — Delivery of the Appendages. 



233 



outward. Effusion of blood may exist but it plays only a secondary 
role. According to Baudelocque, the hsemorrhage is inevitable and 
indispensable ; according to Duncan, it is accessory and may be 
absent (Fig. 282). 

If Baudelocque' s theory were exact, it should apply to all cases. 
But it cannot be accepted in placenta praevia, and besides the 
haemorrhage of delivery of the appendages is often so slight that it 
could not be called upon to explain the placental detachment. On 
the contrary, Duncan's theory presents no exceptions and should 
be considered as well founded. It is the action of the uterine 
muscular structure which causes the detachment of the placenta 
and of the membranes. 




Fig. 281. — Delivery. 



-First stage. Theory of Baudelocque. S, blood; 
U, uterus ; P, placenta. 



Second stage. — Uterine expulsion. — The detached placenta falls 
on the uterine circle, where it may present in three different ways, 
by its uterine surface, by its edge, or by its foetal surface 

Presentation of the uterine surface (Fig. 283) takes place in 
about five cases out of one hundred. The placenta covers the 
uterine circle as if it had been originally inserted on the contour of 
this orifice. This presentation is the most rare and can be con- 
sidered as pathological. It is usually due to a vicious insertion of 
the placenta or to partial adhesions of the placenta or of the mem- 
branes. 



234 Accouchement. — Delivery of the Appendages. 

Marginal presentation (Fig. 284) takes place in about twenty 
cases out of one liundred. The edge of the placenta engages in the 
uterine circle, and arrives first in the vagina. The causes are 
analogous to those of presentation of the uteri surface. 

Presentation of the foetal surface (Fig. 285) occurs in seventy- 
five cases out of one hundred. This presentation of the placenta 
should be considered as the rule, or rather, as physiological, the 
others being pathological. It is to the placenta what the vertex 
presentation is to the foetus. 

The general disposition of the placenta is that of a cup, which is 
adapted to the uterus, to the contour of the uterine circle, and 
which is continued by the cord through the vagina and vulva to the 
exterior. The placenta, pushed by the uterine retraction and con- 
traction, opens the uterine circle little by little and also the canal 
which follows it, drawing down the membranes which turn around 
it in proportion to its descent. Tractions on the cord and expression 
complete the detachment of the membranes commenced by uterine 
contraction. Matthews Duncan believes that the uterine canal 
should present a diameter of about five centimetres to allow the 
passage of the placenta. 

Third stage. — Vaginal expulsion. — When the placenta has fallen 
into the vagina completely the woman feels a vague need of pushing. 
Under the influence of some efforts of expulsion the placenta pro- 
gresses toward the vulva, appears at this orifice and finally passes 
it, drawing in its train the membranes. As at the uterine orifice 
the placenta may present by its uterine or by its foetal surface or 
by its edge. In general the presentation is the same at both 
orifices, unless changed by interventions, as tractions on the cord. 
When the placenta presents at the vulvar orifice by its foetal surface, 
the membranes are inverted and the ovum offers an inverse dis- 
position to that which existed in the uterine cavity. AVhen, on the 
contrary, there is a marginal presentation or a presentation of the 
uterine surface, the membranes are not inverted and preserve their 
primitive disposition. 

B. Symptoms and diagnosis. — To recognize the different 
stages of the delivery, either touch or vision may be used, following 
the descent of the cord. Three circumstances may present : 

1. The exploring finger meets the placenta in the vagina. The 
second stage is terminated and the third is in progress. 

2. The placenta is at the level of the uterine circle, or engaged 
in the canal which follows it. The first stage is accomplished and 
the second is in progress. 

3. The finger, as far as it can reach along the cord, cannot feel 
the placental mass. Detachment has not taken place and the first 
stage is in progress. 



Accouchement. — Delivery of the Appendages. 235 




YlG. 282. — Delivery. — First stage. Theory of Matthews Duncan. U, uterus. 




Fig. 283. — Delivery. — Second stage. Presentation of the uterine face. 



236 



Accouchement. — Delivery of the Appendages. 



Digital examination, then, gives exact information, but it presents 
a double inconvenience ; the first, of being painful, and the second 
of exposing to septicaemia. Thus it is better, except in necessity, 
to be content with the examination of the cord. 




Fig. 284. — Delivery. — Second stage. Marginal presentation. 
U, uterus ; S, blood ; P, placenta. 

Examination of the cord. — At the same time that ligature is placed 
on the cord near the umbilicus, a second one should be placed at 
the vulva, as a funicular index permitting the descent of the 
placenta to be followed. When this index is at seven fingers' 
breadth below the vulva, the placenta is, in general, at the uterine 
circle and even engaged in that orifice. When it is still further 
from the vulva, the placenta is in the vagina, the second stage is 
accomplished and the woman feels at this moment a local malaise, 
which excites bearing down. 

By this means one can, without digital examination, diagnosticalo 
with sufficient precision the descent of the placenta. Touch should 
only be resorted to wiien delivery of the placenta does not occur at 
the end of an hour after accouchement, for then a pathological state 
is entered and the physician is authorized to seek the cause of this 
delay. 

Duration. — Physiological delivery of the placenta lasts from some 
minutes to an hour, average of half an hour. A delivery lasting 
more than an hour is pathological. 



Accouchement, — Delivery of the Appendages. 



237 



C. Management of delivery of the placenta. — Four 
methods : Expectation ; traction : expression ; mixed method. 

Method of expectation. — To leave nature to act, when all is physi- 
ological, is a counsel seductive in appearance. But is it so in prac- 
tice ? Must the physician wait near his patient several hours until 
delivery is terminated ? The interest of the woman, above all, is 
responded. But the interest of the woman is not our waiting. It 
is bad practice, on the contrary, not to deliver the patient as soon 
as possible, to be enabled to change her, to give her dry clothes, and 
to permit repose. Thus simple expectation is, in general, abandoned 
and has few chances of making new proselytes. 




Fig. 285. — Delivery. — Second stage. Presentation of the foetal face. 
S, blood : P, placenta. 

Method of traction. — The principle of this method consists in aiding 
the exit of the ovuline appendages by tractions exerted on the cord 
(Fig. 286). The third stage is the moment of choice for this traction. 
The cord should be seized with a dry cloth and drawn gently out- 
ward. When the placenta apens the vulvar orifice it is grasped 
with the free hand and carefully delivered with the membranes. 

Method of expression. — To replace the vis afronte by the vis a tergo 
has been the idea from which this method arose. In the place of 
drawing, it is thought preferable to push (Fig. 287). Crede's name 
is generally attached to this method. The cord is no longer to be 
touched. After the exit of the foetus, almost at once (Winckel), or 



238 Accouchement. — Delivery of the Appendages. 

at the end of a certain time, wlien uterine contraction returns 
(Breisky), the uterus is grasped A^ith the whole hand and squeezed 
like a sponge. By this expression uterine retraction and contraction 
are aided, diminishing the capacity of the uterus and obliging the 
contents to escape. Pressure on the hypogastrium, combined with 
that on the uterus, is sufficient to favor evacuation of the vagina. 



Fig. 286. — Delivery by traction. U, uterus; S, blood; P, placenta; 
R, rectum ; V, bladder. 

Mixed method. — It is to this method that I give the preference, for 
it unites the advantages of expression and of traction (Fig. 288). 

This method should be practiced as follows : During the first 
stage of the delivery, while the funicular ligature has not descended 
to seven fingers' breadth below the vulvar orifice, it is sufficient to 
place one hand on the fundus of the uterus, to assure the progres- 
sive retraction of the organ and to aid it by slight frictions. AYhen 
the first stage is terminated, after having grasped the cord with one 
hand make gentle tractions in the direction of the perinaeum, while 
the other hand expresses the uterus through the abdominal wall. 
This intervention should always be practiced with slowness and 
gentleness. It lasts some minutes, quarter of an hour, sometimes 
half an hour or more. The accoucheur should not forget that he is 



Accouchement.— Delivery of the Appendages. 239 




k/ 




Fig. 287. — Delivery by expression. 




Fig. 288. — Delivery by mixed method. 



240 Post-Partum. 

only to second uterine action. During the third stage the uterine 
expression is continued, but moderated, less in the aim of aiding 
the delivery than in that of preventing inertia and haemorrhage. 
With the other hand the placenta is drawn on by the aid of the cord. 
When the placenta makes its exit it is left to lie in the bed or in a 
receptacle placed at the vulva to receive it. One hand is still 
retained on the abdomen while the other draws the membranes 
progressively outward. The exit of the membranes should be par- 
ticularly slow, for the least impatience at this moment is sufficient 
to cause their rupture and to favor retention. 

After delivery it is well to leave the hand on the fundus of the 
uterus for a quarter of an hour, making slight friction from time to 
time, in the aim of watching retraction and of preventing inertia. 



CHAPTER XIV. 



POST-PARTUM. 

The uterus is evacuated, the post-partum commences, it will be 
continued or not by lactation. The characteristic fact of the period 
is the genital wound, a multiple wound which commences at the 
raw surface left by the placenta and is continued by erosions of the 
cervix, of the vagina and of the vulva. All these ways are open for 
the penetration of microbes. Thus the dominant feature of this 
period is the menace of puerperal septicaemia. 

To study the details of the consequences of labor it is necessary 
to successively consider : 

I. The mother. 
II. The child. 
III. Lactation. 

I. The mother. 

A. Modifications oj the organism. — The maternal organism modi- 
fied by pregnancy, modified also by the accouchement, undergoes 
during the post-partum new changes destined to restore it pro- 
gressively to the normal state. We shall study these phenomena in 
their relation to each system. 

i. Genital system. — The vulva repairs its ruptures by first or 
second intention. The vagina becomes shortened and narrowed. 
The uterus undergoes, in its return to normal state, important 



Post-Partum. 241 

macroscopic and microscopic changes in the body and the cervix. 
The diminution of the volume of the body of the uterus is appre- 
ciated in practice by the height of the fundus of the organ. The dif- 
ferent modifications which affect the uterus in its return to the normal 
state are included in the term involution or uterine regression. 




Uterine 
circle. 



Internal 
orifice. 



External 
orifice. 



Fig. 289. — Uterus Post-partuir.. 

The cervix also undergoes important modifications to regain its 
normal state. The uterus, after delivery and at the beginning of 
post-partum, is composed of three parts (Fig. 289) ; a thick superior 
portion, the body of the uterus, a thin inferior portion consisting of 
two parts, the cervix and an intermediate portion which diminishes 
progressively to form the isthmus. The uterus during post-partum 
is the source of two phenomena of practical interest, the after-pains 
and the lochia. 

AJter-pains. — These are only uterine colics analogous to those pro- 
duced during labor, sometimes during pregnancy, and in some 
women during menstruation. Their characteristic symptom is the 
pain, and the woman compares them to those of accouchement, but 
of less intensity. They may last for three, four, or even five days. 
These after-pains have no other inconvenience than that of being 
painful, but this may become so marked as to require active treat- 
ment : Tincture of digitalis, ten to twenty drops ; tincture of 
viburnum prunifolium, ten to one hundred in twenty-four hours, 
about ten drops every two hours. Uterine massage. Hot cata- 
plasms. Antipyrine, one to two grammes ; hydrate of chloral, same 
dose. Sometimes a hot vaginal injection or an intra-uterine in- 
jection gives notable relief. But the most certain treatment consists 
in the administration of opiates. 



242 Post-Partum. 

1. Lochia. — The lochia is constituted by a genital flow of post- 
partum occurrence. The principal source is the internal surface o^ 
the uterus, and the accessory that of the cervix, vagina and vulva. 

The lochia is : 

From the first to the third day, sanguineous. 

From the third to the sixth day, muco-pus tinged with blood. 

From the sixth to the ninth day, muco-purulent. 

After the ninth day the flow is normally very slight. 

The lochia is composed, in the beginning, of blood, of leucocytes, 
of epithelial cells, of mucus, and sometimes of the debris of 
membranes. Exceptionally the lochia! discharge is very small in 
quantity, in other cases it is copious. 

2. Mammce. — The modifications of the breasts will be studied 
with lactation. 

3. Urinary system. — The urinary secretion is active during the post- 
partum, especially the first few days. The elimination of the solid 
element of the urine is also augmented. We note in the urine the 
frequent presence of glycose. A frequent accident is the retention 
of urine. The bladder, compressed during accouchement, is in a 
state of paralysis, or paresis, during the first days of post-partum. 
To avoid accidents palpation of the abdomen should be practiced at 
each visit during the first few days; Treatment. — Hot cataplasms 
sometimes favor the emission of urine. Allow the patient to sit up 
to accomplish micturition. As a last resource, catheterism should 
be performed, with vigorous antiseptic precautions. 

I TRAVAIL' 



NORMAL STATE 



Fig. 290. — Modifications of the puerperal pulse. 

4. Respiratory and circulatory systems. — The modifications of the 
respiratory system are not yet well known. Those of the circulatory 
system are better understood. The principal phenomena is a 
notable diminution in the number of cardiac pulsations. They may 
fall to thirty-five a minute. This retardation of rapidity is pro- 
duced a little after accouchement and lasts from eight to twelve 
days with a momentary interruption at the third day caused by 
lactation (Fig. 290). The blood undergoes a relative increase of 
the quantity of the fibrin and of the white corpusles. 

5. Nervous system, — After the accouchement the woman is fatigued 



Post-Partum. 243 

in general, but the excitement of labor and the joys of maternity 
most often prevent immediate repose, and this seldom follows before 
the end of two or three hours. Even then it is often interrupted by 
after-pains. Very often after delivery, or a little before, the patient 
has a slight chill without elevation of temperature or acceleration 
of the pulse. This is a physiological phenomenon and without im- 
portance. 

6. The Digestive system. — The appetite quickly returns. Light 
nourishment should be given. Constipation is the rule and must 
be combatted by appropriate measures. 

7. General state {temperature, iiutrition). — The temperature in a 
normal state should never attain 38^ C. during post-partum. When 
this degree is attained, there exists some complication. During 
simple regression, wdthout lactation, nutrition seems active in all 
its x>rocesses. Lactation modifies these conditions. Under its 
influence absorption and elimination appear active, and, on the 
contrary, assimilation and disassimilation are retarded. 

B. Hygiene of post-partum. — Two points remain for discussion: 
Genital antisepsis, and the gradual resumption of the usual mode 
of life. 

Genital antisepsis, — The vulvar toilet should be made with a solution 
of carbolic acid, 1-50, or bichloride of mercury, 1-4000, using old 
linen rags or absorbent cotton (sponges, proscribed because of their 
doubtful asepsis). In the interval of the toilets an antiseptic tampon 
of dry cotton should be applied to the vulva, simply held in place 
by apposition of the thighs. 

Vaginal injections. — Vaginal injections are used to-day by the 
majority of obstetricians, one to three times a day, with a solution 
of carbolic acid or bichloride of mercury. If antiseptic precautions 
have been taken during accouchement and also during the latter 
part of pregnancy, injections during post-partum a.e useless and 
they are not without inconvenience, for they expose to the pene- 
tration of air into the genital organs, a favorable condition for the 
development of septicaemia. In a general way they should be 
reserved for cases w^here antisepsis has been incomplete during 
pregnancy or labor, for those where a grave intervention during 
accouchement has exposed to the penetration of septic agents, and 
finally, for those wdiere some symptom indicates the presence of 
pathogenetic microbes in the interior of the genital organs. 

Intra-uterine injections. — These injections are only employed in 
special conditions, to remedy a beginning septicaemia. 

Gradual resumption of the usual mode of life. — After accouchement, 
in the absence of any complication, the patient should conform to 
the following precept : 



244 



Post-Partum. 



First fortnight — Bed. 
First week : • 

First half — dorsal decubitus. 
Second half — ^lateral or dorsal decubitus at will. 
Second week : 
First half — the head may be raised by two to four pillows. 
Second half — the puerpera may sit up in bed, to eat, nurse, 
etc. At the end of the second week she may get up. 

Second fortnight. — House. 
Third week : 
Lounge and reclining chair. Duration of remaining out of 
bed, an hour more each day : 
First day, one hour. 
Second day, two hours. 
Third day, three hours, etc. 
Fourth week : 

Arm chair; rocking chair, in case of fatigue. At the end of 
fourth week patient may go out. 



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per day. 



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Fig. 291 — Weight of the child during the first year. 

II. Child. 

A. Physiological phenomena. 

1. Weight. — Tha average weight of the new-born is about three 
thousand grammes at the moment of birth. This diminishes one 
hundred grammes during the first two days and is regained in five 
days more, so that at the end of the first week the weight is identical 
with that at birth. The daily augmentation of the child's weight. 



Post-Partum. 245 

outside of these first seven days, is variable, but may be fixed at a 
daily average, as represented in Fig. 291. 

2. Temperature, circulation, respiration. — The temperature is sub- 
ject to an initial depression and then attains its maximum the day 
after birth, then it oscillates between 36° and 37° C. The initial 
depression is greater in proportion as the birth is farther from 
normal term. The number of pulsations oscillate around one 
hundred and twenty per minute. The respiration gives variable 
results. 

. 3. Cord. — The cord, during the days consecutive to birth, desic- 
cates. A groove filled with a purulent serum appears around its 
umbiHcal insertion. The cord falls off spontaneously between the 
third and sixth day. Sometimes there persists a small ulceration 
at the umbilicus that requires dressing. 

4. — Dentition. — Milk teeth (twenty). — The milk teeth appear in the 
following order : 

Median incisors, four toward the sixth month. 

Lateral incisors, four toward the' ninth month. 

First molars, four toward the twelfth month. 

Canine, four toward the fifteenth month. 

Second molars, four toward the eighteenth month. 




Fig. 293. — Order of eruption of the eight incisors (milk teeth). 

All the lower teeth appear before the corresponding upper teeth, 
except in the case of the lateral incisors where this order is inverted 
(Fig. 293). The preceding dates are only approximate. The first 
teeth often appear later than the sixth month and they are ex- 
ceptionally seen at birth. 

The permanent teeth successively replace the milk teeth which fall 
before their appearance. 

Successive order : 
First molars, seventh year. 
Central incisors, eighth year. 
Lateral incisors, ninth year. 
First bicuspids, tenth year. 
Second bicuspids, eleventh year. 
Canine, twelfth year. 
Second molars, thirteenth year. 
Wisdom teeth, twentieth year (eighteenth to twenty-fifth year). 



246 



Post-Partum. 



5. Digestion. — The milk undergoes digestion in the stomach and 
intestine, and is absorbed from the latter. The stools of the new- 
born child pass through three successive periods : 

Meconial period [three days). — The child evacuates the meconium 
accumulated in the intestine during pregnancy. This stool is 
greenish and syrupy. 

Transitioned period {one day). — The meconium is mixed with di- 
gested milk. 

Lactational period. — The residue of the digested milk gives an 
aspect resembling that of scrambled eggs. The stools number, at 
first, from two to four a day, later, toward the second month, from 
one to three. 

6. Cutaneous p)lienomena. — The child passes through three suc- 
cessive phases, which last about three days each: 1. There is an 
acute cutaneous congestion, caused by contact with the air. 2. There 
is a variety of icterus caused by the transformation of the pigment 
deposited by the blood by the congestive phase. 3. The child be- 
comes pale and gradually takes its normal rose color. 




Fig. 295 —Section of the couveuse, 

B. Hygiene. — 1. Vision. — The ejes should be attentively watched 
and carefully inspected at each visit. This precaution is necessary 
on account of the dangers of purulent ophthalmia. 

2. Cries, Sleep. — The cries are normal when they are of slight 
intensity and duration. When they become intense and prolonged 
they indicate suffering, the cause of which should be sought most 
often in hunger, thirst, or obstruction by the clothing. Sleep gener- 
ally follows after nursing. It should take place in the cradle and 
not in the arms of the nurse. The child should be laid on its side 
in the cradle to avoid obstruction of the respiratory passages if 
vomiting ensues. 

3. Toilet. — It will be well to give the child a hot bath of some 
minutes every morning, or to follow the English system of cold or 



\ 



Post-Partum. 247 

tepid baths, commencing during the hot season. During the course 
of t^venty-four hours the ano-genital region should receive two to 
four cleansings, followed by powdering with starch, lycopodium or 
talcum. 

4. Temperature. — The new-born child is very sensitive to the 
thermic variations met in its neAv life. To avoid these changes the 
temperature should be kept as nearly as possible between 16^ to 18°. 
For children born before term the convenses introduced by Tarnier 
can be used with advantage (Figs. 295 and 296). 



Fig. 296. — Exterior view ot the couvtuae. 

III. Lactation. — Maternal lactation.^- After conception and 
during pregnancy, the glandular lobes of the breasts, besides con- 
gestion, assume a notable development by proliferation of their 
elements. If at this time an antero-posterior section is made (Fig. 
297) we note the following details : Beginning at the nipple we find, 
in following a galactophore, that it presents a fusiform dilatation 
and then resumes its former dimensions to finally ramify in the 
lobe to which it belongs. The canals and glands are formed by two 
layers, the eccentric of connective tissue, the concentric of epi- 
thelium. The epithelium is cylindrical in the galactophore, flattened 
and less rounded in the glandular culs-de-sac. This glandular epi- 
thelium plays the essential role in the secretion of the milk and of 
the colostrum. The globules of the milk are formed at the expense 
of the epithelium (Fig. 298) and the other elements are secreted by 
the glandular wall. The colostrum is constituted by the same 
elements as the milk, but differs by being more aqueous and by 
having the globules still contained in the muriform body. 

The establishment of the flow of milk is characterized, during the 
first twelve hours, by an intense congestion of the breasts which 
become painful and tender, then the lacteal secretion is established, 



248 



Post-Partum, 



the tension diminishes and if the woman nurses the secretion con- 
tinues. The estabhshment of the flow of milk is accompanied by 
malaise, often by cephalalgia and acceleration of the pulse. But 
the fever that before antisepsis was often observed at this moment 
was only a slight septicsemic manifestation. Milk fever does not 
exist. In the normal state the sequelae of the post-partum are 
afebrile ; the thermometer should not attain 38° C. 




Thoracic wall. 

Muscular layer. 
Cellular tissue. 

A lobe of th.: mammary gland. 



Areolar muscle. 

( Montgomery's tubercle and ac- 
-< cessory lactiferous duct proceed- 

(ing from an accessory gland. 
Lactiferous sinus. 
Muscle of the nipple. 

Openings of the lactiferous duct. 



Montgomery's tubercle and ac- 
cessory lactiferous duct proceed- 
ing from a lactiferous sinus. 
Areolar muscle. 



A lobe of the mammary gland. 



Cellular tissue. 



Fig. 297. — Schematic section of the breast. 

With regard to allowing the woman to nurse the child, this de- 
pends upon the general and the local state. The majority of chronic 
diseases are not a contraindication for lactation, among them 
tuberculosis merits special mention. Every woman subject to 
tuberculosis, or even predisposed to this disease, should renounce 
lactation. Hysteria and pronounced anaemia are also contraindi- 
cations. 



Post-Partum. 



249 





o 
o 



oO 

0° 







o O 



O O 














o 
o 





^0 



O OO 

(c) 

Fig. 298. — Formation of milk globules. (A), epithelial cell; (B), distention of the 
cell by fatty granules ; (C), rupture of the cell, freeing the milk globule. 

A flat or umbilicated nipple renders lactation difficult, sometimes 
impossible, but often this can be remedied, as will be seen later. 
The development of the gland and the abundance of colostrum 
should be taken into serious consideration. However, so far as 
local examination is concerned, great reserve is necessary, for often 
the physician is wrong in his prognosis. 




Bodiiv- 





Auvara 



4u^'arri 



Fig. 299. — Breast pumps. 

If the nipple be flattened the child's lips are unable to suck. Even 
when it is normal, the manipulations of the child may produce 
fissure that becomes very painful. To obviate the difficulties in 
such cases the breast-pump will be useful (Fig. 299). 



250 Eclampsia. 



CHAPTER XV 



PUERPERAL PATHOLOGY.— GENERAL 
DISEASES.— ECLAMPSIA. 

An intense influenza may exceptionally cause abortion or pre- 
mature delivery. Typhoid fever causes premature expulsion in a 
good half of cases. The same is true with regard to cholera. Preg- 
nancy confers a relative immunity against malaria. In cases of 
intermittent fever during pregnancy, quinine seems to concentrate 
its influence against the malarial condition and, far from being 
abortive, prevents premature expulsion. The exanthemata occurring 
during pregnancy cause abortion as follows : Measles in one-half 
of the cases; scarlatina in a proportion difficult to establish; with 
the confluent form of small-pox abortion is the rule ; vaccination of 
the pregnant woman does not interrupt the progress of pregnancy. 
Erysipelas during pregnancy often causes premature expulsion 
and its prognosis during the post-partum is always serious. Eheu- 
matism occurring during the puerperal state may show itself in 
three forms — a more or less generalized articular rheumatism, a 
mono- articular rheumatism, and finally, a uterine variety, simply 
characterized by uterine pains. 

Pregnancy by aggravating scrofulosis predisposes to the develop- 
ment of tuberculosis. The majority of phthisical patients are 
badly influenced by the puerperal state. Beskle tuberculosis inter- 
feres with the development of the foetus. This disease is transmitted 
through the placenta. 

Pregnancy occurring during the evolution of sj^philitic mani- 
festations aggravates their character and prolongs their duration. 
If the onset of syphilis dates back several years, its influence on 
pregnancy will probably be nul and the child unaffected. If syphilis 
is transmitted to the woman at the moment of conception, the child 
will almost surely be syphilitic. When syphilis is transmitted to 
the woman after conception, during pregnancy, the contamination 
of the cliild is to be feared in proportion as the beginning of the 
disease approach the date of conception, and less to be dreaded as 
it is near term. 

Eclampsia. — Eclampsia is a disease characterized by a series 
of convulsive attacks analogous to those of epilepsy, occurring at a 
variable period of the puerperal state, most often near accouchement. 



Eclam;psia, 251 

Symptomatology. — Prodromata, though often wanting, are more 
frequent in eclampsia of pregnancy than in that of labor, and in 
eclampsia of labor than in that of post-partum. They consist of 
cephalalgia, especially frontal, with weakening of the memory and 
intellectual apathy, bilious or alimentary vomiting, insomnia, 
malaise, vertigo, and sometimes prolonged lumbago. 

But the three principal prodromata, which constitute a sort of 
premonitory tripod, are : 

The disturbances of vision (visual fatigue, cloudiness, hemiopia, 

diplopia, complete blindness). 
The epigastric pain (result of the dyspnoea). 
The dyspnoea (result of the insufficiency in the functions of the 

lungs). 

Sometimes these prodromata follow several days or weeks before 
the first attack, again, they may only precede it by a few seconds. 

Albuminuria can also be considered as one of the most important 
of the prodromata of eclampsia, but, it is convenient to separate it 
from the preceding symptoms, which are subjective, as it can only 
be found by the use of objective researches. 

Lead poisoning very frequently causes the death of the foetus 
during pregnancy, and also that of the child after birth, on account 
of its lack of development. The influence of the husband is analo- 
gous to that of the mother, though less marked. Poisoning by 
tobacco occurs by the penetration of nicotine into the amniotic 
liquid during pregnancy and into the milk after accouchement. 
The influence of this poisoning on the production of abortion 
although probable is, however, disputed. 

Under the term progressive pernicious anaemia, Gusserow has de- 
scribed a disease of pregnancy characterized by the progressive 
diminution of the red globules, terminating in anaemia and in death. 
This disease is probably only an exaggeration of the anaemia common 
to pregnancy. 

Attack. — The attack of eclampsia is subdivided into four periods, 
invasion, tonic spasm, clonic spasm and coma, foUowed by an in- 
terval of calm. 

1. Invasion {duration half a minute). — The face is the part first 
attacked. The forehead wrinkles and becomes smooth ; the eyelids 
lower and raise ; the ocular globe turns in various directions until 
the pupil is carried upward ; the pupil is dilated and insensible to 
light ; the wings of the nose are pinched and depressed ; the mouth 
twitches and is soon drawn to one side, most often to the left ; the 
head undergoes occillations drawing it to the right or left and soon 
fixing it definitely to the left. 

2. Tonic spasms {cluration one minute). — After these facial move- 
ments, a second period follows characterized by generalized tonic 



252 Eclampsia. 

convulsions. The features become immobile ; the head is drawn 
backward ; the thorax is fixed ; respiration suspended ; the arms 
are against the body, the forearms in pronation, the fingers closed 
and around the thumb ; the abdominal wall is tense ; the lower 
limbs stiffened. Often the body describes an arc of a circle with 
its two extremities, the head and feet, supported by the bed. The 
respiration being suspended, the circulation is interrupted so that 
a general cyanosis quickly follows. 

3. Clonic sjjasms {duration two to three minutes). — The clonic 
convulsions invade the whole body^ from the head, where they com- 
mence, to the feet. The face is agitated by movements analogous 
to those of the onset, but more violent and more prolonged. The 
tongue projects between the teeth and is often bitten. After the 
face, all the head, then the thorax, the upper limbs, the abdomen 
and, finally, the lower limbs become involved in convulsive move- 
ments. This general convulsion soon gives way to coma. 

4. Coma {duration quite variable, from some instants to several 
hours). — Affcer the period of agitation there follows a comatose 
sleep. Then the patient returns to her senses completely, or she 
remains in a state of somnolence, or finally, she does not recover 
from the comainto which she has been plunged by a last attack. 
Besides the symptoms already given, there is sometimes produced 
an involuntary evacuation of urine and feces, during or at the end 
of the clonic spasms. 

Interval between the attacks. — The duration of this interval is quite 
variable, sometines it is nul, two or several attacks succeeding each 
other without interruption, sometimes it amounts to several hours. 

The temperature sometimes remains normal, or even descends 
below normal, most often it rises to 38-39° C. Its ascension is in 
proportion to the gravity of the case. The pulse follows the temper- 
ature. 

Albuminuria usually exists for some time, occasionally it only 
appears during the attack, exceptionally it is completely wanting. 

The oedema, the puffiness of the face, is accentuated under the 
influence of the attack, to such a point that the swelling of the face 
renders the person unrecognizable. 

Duration. — Sometimes the eclampsia is confined to a single attack 
and only lasts a short period. Usually there are from five to twenty 
attacks. But their number may be much more considerable, as 
Crettet cites a case having one hundred and sixty. 

Terminations. — Cure occurs by a simple cessation of the attacks 
and of coma. It may be complete, or incomplete leaving behind it 
disturbances of memory and of vision, an habitual stupor and slow- 
ness of action, a persistent anaemia and even mania. Death is pro- 
duced by the progress of the poisoning of eclampsia, exceptionally 
during the attack by asphyxia and syncope, by a complication, 



Eclampsia. 253 

pulmonary congestion and oedema, cerebral haemorrhage and oedema, 
asphyxia resulting from a considerable swelling of the tongue, and 
by independent complications, such as puerperal septicaemia or 
grave genital haemorrhages. 

Pathological anatomy. — Varied lesions are found but none of them 
are constant. 

Nervous system. — Serous infiltration, congestion, anaemia, haemor- 
rhages of the meninges. 

Re sjnratory system. — Lungs, congestion, apoplexy, oedema, em- 
physema. Pleural cavities, serous infiltration. 

Circulatory system^ — Heart, puerperal modifications. 

Urinary system. — Frequent but not constant alteration of the 
kidneys, presenting a simple hyperaemia, or the lesions of a recent 
or an old nephritis. 

Digestive system and appendages. — In the digestive system, only 
the state of the liver is of importance. This organ may be the seat 
of an advanced fatty degeneration, multiple haemorrhages, lesions 
of diffused iDarenchymatous hepatitis. 

Genital system. — State of the organs in relation with the period of 
the puerperal state in which death takes place. 

Pathogeny. — I present in resume in the following table a view, as 
a whole, of the different theories, comprising therein the theory of 
general arrest of organic elimination with which I will close. 

Pathogenetic theories of eclampsia. 

A. Eclampsia — neurosis. 

1. Mauriceau. 

•2. Cohen : neurosis, having its point of departure in the 
uterine reflex. 

B. Eclampsia — modification of the nervous centers. 

1. Mauriceau: congestion or anaemia. 

2. Marshall de Calvi : cerebral oedema. 
8. TrauLe : anaemia followed by oedema. 

C. Eclampsia — alterations of the blood. 

1. Eenal theory, 1818. Blackall and Wells (Cotugno). 
Uraemia — Wilson 

Frerichs : formation in the blood. 



Amnionaemia — < m •- n x- • xi • x x- 

Treitz : lormation ni the intestines. 

Creatinaemia — Schottin. 

Urochronaemia — Thudichum. 

Oxalaemia — B. Jones. 

Potassiaemia — Despine. 

Urinaemia — Peter. 

2. Theory of general elimination, 1818. Eiviere and 

Anvare. 



254 Eclamj)sia. 

Neurotic eclampsia is not accepted at present, nor is the influence 
exercised by the modifications of the nervous centers. 

The renal theory contains a large portion of the truth. However, 
it is not completely satisfactory for the following reasons : 

1. Apyrexia is the rule in urinsemia and, on the contrary, fever in 
eclampsia. 

2. The urinary secretion is sometimes, although exceptionally, 
normal in eclampsia (eclampsia without albuminuria). 

3. Sometimes eclampsia presents a great analogy mth grave 
icterus (diffuse parenchymatous hepatitis), the origin of which can- 
not be related to urinsemia. 

These objections disappear if, in place of localizing in the kid- 
ney, the functional disturbance which causes eclampsia, is extended 
to all the eliminating organs. So far as these different organs are 
concerned we have : 

Kidneys. — Urinaemia ; albuminuria ; anuria. 

Liver. — Hepatsemia ; "^ icterus; acholia. 

Intestine. — Intestinsemia ; constipation. 

Lungs. — Pneumsenia ; dyspnoea. 

Skin. — cutsemia; cutaneous dryness. 
Among the different symptoms, indicating the functional dis- 
turbance of the eliminating organs, the cutaneous dryness and the 
constipation (which is actually an intestinal dryness) are of small 
importance on account of their frequence and common occur- 
rence. Dyspnoea is a marked premonitory symptom of eclampsia. 
Icterus hardly ever occurs except during eclampsia itself, but it is 
far from being rare, especially in serious cases. The acholia is 
only incomplete and difficult of appreciation. The anuria some- 
times becomes complete during the attack, but as a premonitory 
symptom there is only observed a diminution of urine. — Albumin- 
uria is the most important premonitory symptom. 

jEtiology. — Parity: proportion, four primipar^e to one multi- 
para. Tmn pregnancy and, in general, any exaggerated distention 
of the uterus predisposes to eclampsia. Any difficult accouchement 
may become a cause of this disease. Heredity seems to play some 
part in the production of eclampsia. Compression of the ureters or 
of the urethra (retention of urine) by the gravid uterus may become 
a cause, by interrupting the function of the kidney. Blot has 
demonstrated that eclampsia is most frequent among epileptics. 

* Hepat(zmia indicates the accumulation in the blood of all the elements produced by 
the default of the hepatic function (suppression of the uro-poietic, haemato-poietic and 
biliary functions) or by a deviation of function (bile secreted and thrown into the blood). 
For the intestine I also say iniestincEmia, and not stercorceinia, for stercorsemia indi- 
cates the presence in the blood of material contained with the feces, while here there 
is more a suppression of those that furnish the intestinal secretion . Likewise pneumcemia^ 
and not asphyxia, for asphyxia is the simple deprivation of oxygen, while I note es- 
pecially the absence of the elimination of the toxic alkaloid. Finally, for the skin, we 
have cutsemia and not sudorgemia. 



Eclampsia. 255 

The contagion of eclampsia itself cannot be admitted, but a disease 
of tlie eliminating organs (infectious nephritis, infectious pneu- 
monia) may, by contagion, indirectly cause an evolution of puer- 
peral convulsions. 

Frequency. — Albuminuria exists in about one-tenth of pregnent 
women, and eclampsia in one thirty-fifth of the albuminurias of 
pregnancy, giving a proportion of eclampsia of one three-hundred- 
and-fiftiehs of pregnant women. 

Prognosis. — About one-quarter of the cases of eclampsia die, and 
two- thirds of the children succumb. 

Treatment. — The therapeutic means that are employed against 
eclampsia are very numerous. They can be grouped as follows : 

{Revulsives. 
Diaphoretics. 
Baths. 

-p.. ,. ^ f Purgatives. 

2. Digestive system | ^^^^^^^^ 

TT • ^ r Diuretics. 

3. Urinary system | y^^^^^ 

4. Respiratory system — Oxygen. 

^ ^. , ^ ^ f Compression of the carotids. 

5. Circulatory system | Venesection. 

/. TVT if Sedatives. 

6. Nervous system I ^^^^^j^^^.^^^ 

f Premature rupture (artificial) of the membranes. 
I Induced accouchement. 

7. Genital system ] Active accouchement. 

I Forced accouchement. 

[ Caesarian operation post-mortem. 

8. Various medications. 

9. Minor attentions. 

I shall enter into the details of these various means and the 
results they have afforded. I shall only indicate the use of the 
best and the most efficacious among them for ; 

A. Preventive treatment. 

B. Curative treatment. 

C. Consecutive treatment. 

A. Preventive treat7nent. — The necessity for watching for the ap- 
pearance of albumen in the urine of the pregnant w^omen is well 
understood. The preventive treatment par excellence consists in 
the milk diet, continued as long as there is albumen in the urine. 
Induced accouchement will be reserved for quite exceptional cases. 
In grave, menacing cases, where plethora is clearly present, it be- 
comes necessary not to hesitate in maldng a venesection of three 
hundred to five hundred grammes. 

B. Curative treatment. — Among the minor attentions, a handker- 
chief should be placed between the teeth to prevent biting the 
tongue. In cases of exceptionally grave eclampsia the suspension 



256 Eclampsia, 

of respiration for some time may be the cause of death. It will be 
well then to attempt artificial respiration. 

With regard to curative treatment proper, the means to be em- 
ployed can be grouped in six divisions ; three of capital importance, a 
maj or therapeutic tripod, and three of secondary importance, a minor 
therapeutic tripod. The major tripod consists of anaesthesia, of vene- 
section and of uterine evacuation. 

In a general way, we may say that anaesthesia should be applied 
in every attack of eclampsia. It will be obtained by the use of 
chloral or chloroform. Chloral should be given in as high a dose 
as possible, 10, 14, 16 grammes in twenty-four hours, and as much 
as possible by enema. Chloroform will be administered to com- 
plete anaesthesia and in a sufficient dose to keep the patient in a 
state of calm. 

Bleeding will be employed in plethora, when the convulsions are 
violent and when the coma is accompanied by symptoms of as- 
phyxia. According to the case, there will be removed five hundred 
to one thousand grammes, exceptionally more. 

With regard to emptying the uterus, we seek to obtain this as 
promptly as possible, but without having recourse to violent 
measures. If labor is not declared, spontaneous contractions will 
be awaited, except on special indications, when accouchement will 
be induced. If dilatation has commenced, forced accouchement 
will be avoided unless there is present a menacing danger to the 
mother, when it will be authorized. As soon as dilatation is com- 
plete the accouchement must be terminated by the forceps or by 
version and extraction. The delivery of the appendages will be 
equally active witliin the limits prescribed by prudence. 

In our minor tripod are placed purgatives, diuretics and sudorifics. 
It is not necessary to discuss them as these remedies are common 
to general medicine. 

C. Consecutive treatment. — The consecutive treatment may be 
summed up in a double indication, for one part, to remedy the dif- 
ferent complications which succeed to eclampsia, for the other to 
prevent the return of the disease by removing the cause and adopt- 
ing preventive therapeutic means. 



Puerperal Septiccemia, 257 



CHAPTER XVI. 



PUERPERAL SEPTICAEMIA. 

It has been reserved for Pasteur to make known the microbic 
nature of the causal element of this disease. The microbes met in 
puerperal fever are of four varieties : 

1. The bacilli in rod-like forms, cylindrical bacteria, the cause of 
rapid septicaemia. 

2. The micrococci in chaplet-form, the source of an attenuated 
septicaemia. 

3. The micrococci in double points (the diplococcus) the cause of 
suppuration. 

4. The micrococci in isolate points, of a role not ^-et well es- 
tabhshed. 

Though the respective part played by each of these varieties is 
still unsettled, their microbic influence, considered in a general way, 
is beyond contest, so that puerperal septicaemia is, without doubt, 
a microbic affection. 

We have now to see how these microbes arrive in the feminine 
organism, that is, the aetiology of pueri)eral septicaemia. Let us 
compare the pregnant woman to a fortified and besieged city ; a 
projectile produces a break in the ramparts, the same as accouche- 
ment a series of wounds at the genital surface of the woman. What 
results from this breach? If the enemy be distant the besieged 
will have time to repair the gaps before their arrival, the same as 
during post-partum, nature cicatrizes the genital wounds against all 
aggressions of the microbes. If, on the contrary, the enemy be 
near, they attempt to penetrate and a sharp struggle ensues. This 
struggle in the breach represents the inflammation of the genital 
wounds (localized septicaemia). If the organism is victorious, the 
microbes are repulsed, all is confined to the local septicaemia. But, 
on the contrary, if the assailants are successful the city is invaded, 
the combat becomes general. In the same way if the microbe pene- 
trates into the economy its triumph causes the death of the woman; 
its defeat, cure. 

To comprehend this struggle we have to examine : 

1. The state of the besieged city (puerperal state). 

2. The breech (genital wounds). 

3. The enemy or the assailants (microbes). 

4. The passages leading to the city and into its interior 
(mode of arrival and of penetration). 



258 Puerperal Septiccemia. 

1. Puerperal state. — The modifications produced by puerperality, 
in particular in the composition of the blood, are seen to predispose 
to the invasion of the septic temic microbe. 

2. The genital icound is multiple and composed of the surface of 
the placental insertion, as well as the solutions of continuity existing 
in the cervix, the vagina, and the vulva. Any wound outside the 
genital sphere, notably those of the nipples, of the skin (excoriations 
of the buttocks, etc.), may lead to the same results. Sometimes the 
penetration occurs by the urinary passages (cystitis, infectious ne- 
phritis), notably in consequence of a septic catheterism. May the 
microbes also enter by a solution of continuity of the digestive and 
respiratory passage ? This is possible but it has not been demon- 
strated. 

3. The microbes have been previously described. Each sudden 
invasion that they make into the organism is marked by a chill. 

4. Mode of arrival and of penetration : 

a. Arrival at the organism. — In a certain number of cases, perhaps 
more frequently than has been supposed, the i)uerperal microbes 
are found during pregnancy in the vagina and cervical canal, 
simply waiting favorable conditions to multiple and penetrate into 
the maternal organism. This multiplication will be favored during 
pregnancy by any local suppuration (vaginitis), by the flow and the 
stagnation of blood (haemorrhages), and after accouchement, by the 
putrefaction of debris retained in the uterus. Outside of these 
cases, the carrier of the microbes to the organism may be a liquid 
(non-sterilized injection), or a solid body (materials of dressing, in- 
jection canula, obstetrical instruments, finger of the attendant, etc.). 
May a gaseous body, the air for example, serves as a carrier for 
puerperal microbes? The generality of obstetricians admit that 
transmission by the air is impossible. It will be wise, however, to 
act as if contagion through the air were possible. 

h. Penetration into the organism. — The microbes penetrate into 
the organism : 

By way of the blood, veins : phlebitis, symptoms of rapid generali- 
zation. 

By way of the lymphatic vessels : lymphangitis, phlegmon, aden- 
itis, inflammation of the serous membranes (notably peritonitis). 
Symptoms of diffusion in general much slower, the glands often 
forming an impassible barrier, such are cases where the septi- 
caemia especially evolves as a local affection with only slight general 
reaction. 

In some cases of puerperal fever, it is impossible to detect any 
mode as contagion and septicaemia appears to be spontaneous. 
This is a false interpretation, the ways of contagion are multiple 
and sometimes difficult to recognize, and besides, contagion is 



Puerperal Septiccemia. 259 

possible by tbe intermediary of microbes remaining some time in 
the genital organs. 

Pathological anatomy and symptomatology. — Puerperal septicaemia 
begins exceptionally during pregnancy or accouchement, but almost 
always from the second to the tenth day after delivery. It may 
assume quite varied clinical forms, making its description difficult. 
For clearness I shall adopt seven types, including the principal 
forms from which the secondary or mixed forms may be derived. 
I shall also speak of some special forms in terminating. 

1. Generalized form ivithout lesions. — Acute non- suppurating septi- 
ccemia. — After accouchement, intense chill the following day and 
the day after. Eapid ascension of temperature to 40° to 41° C. 
Great acceleration of the pulse, which soon becomes irregular, im- 
perceptible. Intense and progressive dyspnoea. Face pale, livid, 
sometimes cynotic, tongue red and dry. Abdomen scarcely swollen. 
Vomiting sometimes marked, sometimes wanting. Black and ex- 
tremely fetid diarrhoea. Urine scanty, very albaminous. No trace 
of localization. Acute terminal delirium, sometimes giving place to 
coma in the last moments. Death in thirty-six or forty-eight hours 
or in three days. The autopsy remains negative. Bacteriological 
examination of the blood alone demonstrates the presence of culpa- 
ble microbes. 

Sometimes in place of this early beginning and rapid march,, 
fever appears, preceded by one or several chills, somewhat later 
taking a certain analogy with that of typhoid fever, with sometimes. 
an ataxic predominence, sometimes an adynamic. The patient 
succumbs in some days in a coma which has succeeded to delirium, 
or with pulmonary complications. 

2. Generalized form ivitli lesions. — Acute suppurative septiccemia. — 
This form is characterized by the formation of multiple abscesses, 
probably of venous origin (infectious phlebitis), which may occupy 
any part of the organism. The general symptoms exist alone in 
the beginning, during a certain time, and are then followed by 
various abscesses. The appearance of the symptoms is later than 
in the acute non- suppurative form. The initial chiU scarcely ever 
occurs before the fifth day and sometimes not before ten or fifteen 
days and even more. This chiU is usually intense and prolonged. 
x\fter this first chill, the state does not appear grave, except a fever 
which presents great variations. But a second and a third chill 
quickly follow, usually violent and without periodicity. The general 
state is aggravated, the skin is dry, the face pale, the appetite nul, 
the tongue red, the thirst excessive. Diarrhoea is abundant and 
fetid. The urine is scanty and almost always albuminous. The 
chills succeed in variable number. Their interval at the beginning 



260 Puerperal Septiecemia. 

is marked by periods of complete apyrexia. But soon the fever 
becomes continuous, intense and contributes to the aggravation of 
the general state. Thus far the most attentive local examination 
reveals no localized lesion and, except a slight painfulness which 
sometimes exists about the broad ligaments, the manifestations of 
the disease reveal no distinct state in any organ. 

But after a number of days, which most often vary from eight to 
fifteen after the first chill, follows a second period in which multiple 
abscesses are shown. The suppurations may occupy any part of the 
organism, I shall only mention their seats of predilection : 

Genital organs. — Abscess of the broad ligament, the size of a pea 
to that of an apple and even more. Pus in the uterine sinus and 
in the tubes. 

Nervous system. — Suppuration of the meninges. Suppurative 
phlebitis of the sinuses. Abscess in the cerebral or medullary 
parenchyma. 

Respiratory system. — Purulent pleurisy. Infarctus and abscess 
of the lungs. 

Circulatory system. — Suppurative pericarditis. Ulcerous endo- 
carditis. Abscess of the cardiac wall. Small phlebitic or peri- 
phlebitic abscess at any point of the body. Infarctus and abscess 
of the spleen. 

Digestive system. — Abscess of the dependent glands, notably the 
liver, of which infarctus (miliary abscesses or larger) are excessively 
frequent. 

Urinary system. — Besides the vesical complications are frequently 
noted infarctus and multiple abscesses of the kidney, also a peri- 
neal suppuration. 

Regions. — Abscesses of the cellular tissue. Echars of the pro- 
jecting regions (trochanter, sacrum). Articular abscess. Suppuration 
of the synovial tendons. Abscesses cf the periosteum and of the 
bone itself. 

These various suppurations are manifested by their usual symp- 
toms, hidden here in the importance of the general symptoms. Let 
us simply note icterus in the hepatic complications and the stetho- 
scopic phenomena in the pulmonary complications. 

Cured cases are the exception; death is the rule. It follows 
under the influence of the progressive poisoning of the organism, to 
which the functional disorders caused by the visceral suppurations 
are auxiliary. 

3. Peritonceal form — peritonitis. — Puerperal peritonitis takes its 
origin in the genital organs. Sometimes it is consecutive to an in- 
flammation first localized in the pelvic cavity ; sometimes it is 
primary. This generalized peritonitis is one of the most frequent 
forms of puerperal septicaemia. It is usually announced by a violent 
pain and an intense chill. The pain arises in the uterus and soon 



Puerperal Septiccemia. 261 

radiates to all the abdomen with progressive swelling. The patient 
lies on the back, immobile, so as not to increase her s>ufferings. The 
face shows the pain and takes that special expression met in peri, 
tonaal affections. The tongue is dry, the thirst acute, the hiccough 
almost continual, the vomiting incessant, first alimentary, then 
bilious. Diarrhoea is the rule and in contrast with the usual con- 
stipation of non-puerperal peritonitis. 

Eespiration becomes difficult, and the dyspnoea seems to increase 
in proportion to the distention of the abdomen. The fever is high, 
the pulse frequent, the lochia is Httle abundant and usually fetid. 
The lacteal secretion dries up, or, if not yet established, it is not 
produced at all. 

Cure may take place, when the disease is vigorously combatted 
at the onset, then the symptoms progressively diminish. But the 
most usual termination is in death, which follows, either under the 
influence of the progressive asphyxia due to the poisoning of the 
whole organism and to the distention of the abdomen, or under the 
influence of the extension of the inflammation to the pleura and to 
the pericardium. 

The lesions found in the autopsy are those of suppurative peri- 
tonitis. 

4. Periuterine form — pelvic peritonitis. — Phlegmon of the broad lig- 
ament. — In proportion as we advance in this description, we see the 
septicaemia become more and more localized and its gravity de- 
crease. In fact, the more septicaemia becomes localized, the better 
is its prognosis. 

Chills followed by fever and pain are the symptoms which, here, 
as in peritonitis, open the scene, but their intensity is less than in 
this last disease. 

The general symptoms are nearly the same in pelvic peritonitis 
and in phlegmon of the broad ligaments and may be resumed in a 
febrile state, more or less marked in relation with the gravity of the 
local conditions, but the progress of these affections is essentially 
different and requires separate description. 

a. Pelvic peritonitis is msimiested by a swelling at the posterior 
cul-de-sac of the vagina. There is constituted at this point a tumor 
which pushes the uterus forward and upward. If resolution occurs 
this tumor takes a harder consistency and becomes progressively 
smaller and more indurated. If suppuration takes place the tumor 
increases in volume and in place of induration fluctuation is found. 
This abscess, encysted by false membranes, may, exceptionally, be 
absorbed. More often it opens into the vagina or rectum, or into 
the peritonaeum. Opening into the vagina or rectum, whether arti- 
ficial or natural, lead to cure at the end of a variable time. The 
opening of the pus into the peritonaeum causes a general peritonitis, 
quickly fatal in a majority of cases. 



262 Puerperal Septicaemia. 

h. Phlegmon of the broad ligaments. — This phlegmon is usually 
unilateral, and more often on the left than on the right. It forms a 
tumor analogous to that of pelvic peritonitis but occupies the lateral 
cul-de-sac, pushing the uterus toward the healthy side. Eesolution 
may occur by induration and progressive diminution, or by suppu- 
ration. The abscess may be capable of opening into the rectum, 
vagina, peritonseum, or bladder. The suppuration may also open 
externally through the abdominal wall. 

5. Uterine form — metritis. — Uterine septicaemia or septic metritis, 
begins by pain and elevation of temperature, but usually the initial 
chill is wanting. The pain is very acute and at first simulates that 
of peritonitis. But it is localized in the subumbilical region of the 
abdomen and it is only pressure on the uterus that aggravates it. 
This metritis may give rise to a contiguous inflammation, even to 
a generalized peritonitis, but usually, especially when properly 
treated, it terminates in resolution, or degenerates into a chronic 
parenchymatous metritis. 

The general state is usually but slightly affected. The lever is 
moderate, the temperature, aside from complications, rarely passes 
39" C. Cure is the rule. 

6. Vulvo-vaginal form — vulvo-vaginitis. — After delivery, especially 
from the third to the fifth day, there is often found on the internal 
surface of the labia and on the terminal portion of the vagina 
grayish surfaces of gangrenous aspect, like exudates of diphtheritic 
appearance, to which has been given the name vulvar or vaginal 
eschars. These eschars are only the local manifestation of puer- 
peral septicaemia. 

In some cases they are not accompanied by any general reaction, 
and, under the influence of local care, the exudation disappears 
and cicatrization occurs without accident. 

But in other cases they become the origin, exceptionally, of phle- 
bitis, more often of a lymphangitis, which induces adenitis of the 
inguinal glands, causing, by propagation, phlegmon of the iliac fossa 
and even peritonitis. The septicaemia then becomes general and 
assumes an increasing gravity. 

7. Mammary form — mastitis. — As at the vulva, septicaemia may re- 
main absolutely local or extend to more or less distant parts. Local 
it is manifested in the form of fissures, generally situated at the base 
of the nipple. These fissures are deep and covered by a grayish 
coating. From the nipple the septicaemia may follow different ways 
to reach the gland-producing abscess of the breast, or it may reach 
the axillary region by the lymphatics, producing adenitis, and pass- 
ing this point may cause general septicaemia, though the last is 
scarcely ever observed. 

In the great majority of cases the mammary septicaemia is 



Puerperal Septiccemia, ^QS 

confined to the lesions of the nipple and of the mammae, with a 
general reaction in relation with these local accidents. 

8. Special forms . — a. Cystitis and nephritis. — This form of puerperal 
septicaemia is rare. During pregnancy or after delivery, in con- 
sequence of a septic catheterism, a cystitis is declared ; the inflam- 
mation follows the ureter to the kidney, an infectious nephritis is 
the result, and is manifested by its usual symptoms. This nephritis 
may be the cause of puerperal convulsions. 

b. Phlebitis of the lower limbs. — This phlebitis is generally known 
as phlegmasia alba dolens. It presents two forms, especially dif- 
ferent in their initial period. 

The first generally begins about the fifteenth day of post-partum, 
when, since accouchement, the apyrexia has been complete and the 
condition as satisfactory as possible. At this moment there occur 
a moderate fever and a pain in the iliac fossa or in the calf of the 
leg. Then the phlegmasia runs its course and lasts from one to 
three months. 

The second succeeds to other septicaemic manifestations, fever 
and chills, onset of peritonitis, etc. The various symptoms appear 
three to six days after accouchement and at first no clear locali- 
zation can be found, then, the phlebitis is declared and the septi- 
caemia becomes localized in the veins of the lower limbs. 

c. Paralyses. — Besides paralyses occurring during the puerperal 
state, under the influence of causes independent of that state, and 
not including pareses of the lower limbs, which result from compres- 
sion during accouchement, there exist hemiplegias and paralyses 
still incompletely understood and which appear of septicaemic na- 
ture. Their prognosis is in general benign. 

d. Puerperal eruptions. — Besides the eruptions independent of the 
puerperal state, there is sometimes seen after delivery erythe- 
matous plaques, the confluence of which recalls the aspect of the 
skin in scarlatina. This eruption seems to be a simple cutaneous 
manifestation of puerperal septicaemia. 

Prognosis. — The gravity of the prognosis will vary : 

With the form of the disease ; the more localized the septicaemia 
the better its prognosis. 

With the period of its beginning; in general the prognosis is 
better in proportion as the onset is distant from the moment of 
accouchement. 

With the intensity of the fever ; the more pronounced the thermic 
elevation, the more grave is the prognosis. 

With the surroundings of the patient ; if the case is isolated it has 
more chance of being benign. In a series of successive contagions, 
the poison appears ^to gain intensity. 



264 Puerperal SepticcEmia. 

AVith the treatment ; the majority of cases of septicsemia (except 
those generalized at first), well treated, should be cured. 

Treatment. — So far as prophylactic treatment is concerned it will 
be understood that the antisepsis must be perfect in relation to the 
attendants, physician and nurse, to the instruments, and to all the 
surroundings of the patient. 

With regard to the post-partum three circumstances may present 
— the normal state, a menace of septicsemia, and finally a fully 
established septicaemia. 

1. Normal state. — ^A^ulvar toilets are sufficient unless there is 
reason to doubt the ascepticism of the genital organ, when vaginal 
injections will be necessary, one to two a day, with a carbolic (1-50) 
or a boracic (3-100) solution. These injections should be given by 
the physician or by an intelhgent nurse who understands how to 
avoid the penetration of air. 

2. Menacing septiccemia. — Whenever we have present : 

Ketention of a portion of the appendages (placenta, 

ovuline membranes) ; 
Cephalalgia; 
Fetidity of the lochia. 

It is necessary to fear the appearance of septicaemia and to take 
measures to prevent its development. In such cases frequent 
vaginal injections will be given, two to four in twenty-four hours, 
with one to two litres of a carbolic solution, 1-50. 

If the lochia is fetid and if, in spite of , repeated vaginal in- 
jections, the odor persists, it is necessary to have recourse to intra- 
uterine injections, repeated twice a day until the normal state 
returns. 



Fig, 303. — Budin's intra-uterine sound. 

3. Declared septiccemia. — As soon as septicaemia is declared, that 
is, after the appearance of the chills and of the fever, the treatment 
is nearly the same in all forms, except the mammary, which is 
usually slight, only requiring local care, and except the special forms 
which will not be taken into consideration here. 

The indication is threefold : To clear the genital surface of mi- 
crobes, genital medication ; to prevent the penetration of microbes 
into the organism, abdominal medication; to aid the organism in 
its struggle, general medication. 



Puerperal Septicremia. 



265 



Genital medication. — In cases where the septicaemia is clearly of 
vulvar origin, we may be content with vulvar and vaginal lavages, 
repeated two to four times a day, with carbolic acid, 1-50, or with 
bichloride of mercury, 1-2000, and with dusting the vulva with 
iodoform. But most often intra-uterine asepsis must be assured by 
the use of injections into the cavity of the uterus. The importance 
of this uterine toilet is capital and merits emphasis. I shall suc- 
cessively describe the classic intra-uterine injection and then the 
improvements that I believe are necessary to give this injection its 
requisite efficacy, the perfected intra-uterine injection. 




Fig. 304. — Metallic basin for abundant vaginal irrigation. 

Classic intra-uterine injection. — The best intra-uterine sound for 
this purpose is that recommended by Budin (Fig. 303). The woman 
is left in her usual position, a basin (Fig. 304) is slipped under the 
buttocks. This basin is provided with a discharge tube which 
permits a prolonged injection. After having cleansed the vulva 
and vagina the extremity of the sound, previously dipped in vaseline, 
is directed on the finger of one hand through the vagina to the 
external orifice of the uterus. From this moment the instrument is 
pushed in the supposed direction of the uterine canal. When the 
sound has passed the external orifice it meets at three, four, or five 
centimetres a first obstacle, which is the internal orifice in the 
process of reformation. The obstacle is constituted less by the 
narrowness of the orifice than by the angle formed by the uterine 
wall (Fig. 305). After this obstacle a second is met, some centi- 
metres farther; this is the uterine circle, and when it is passed the 
sound penetrates to the fundus of the uterus v/ithout difficulty. 



266 



Puerperal Eclampsia. 



When the sound has penetrated to the fundus a variable quantity 
of liquid is allowed to flow through it. It is well to use several 
litres of an antiseptic solution (ten to twenty litres). 




Fig. 305. — Post-partum uterus and vagina. C U, uterine circle : O I, internal 
orifice; O E, external orifice. 

The perfected intra-uterine iiijection, — Against the classic intra- 
uterine injection three objections may be urged: 

1. It is often difficult to introduce the sound on account of the 
obstacles created by the internal orifice and by the uterine circle. 
Sometimes it is even impossible to introduce it. Thus many phy- 
sicians, even though experienced, find it impossible to penetrate 
beyond the internal orifice or the uterine circle. 

2. The curved direction of the genital canal, incompletely cor- 
rected by the sound, obstructs the return of the liquid. 

3. The simple contact of the liquid alone is not sufficient to com- 
pletely cleanse the uterine surface, the friction of a solid body is 
indispensable for this effect. 




Fig. 306. — Irrigating curette. 

To remedy these disadvantages I use an irrigating curette (Fig. 
306) perforated through its length by a canal which allows the use 



Puerperal Septiccemia. 267 

of an antiseptic liquid. The terminal ring is sharp on one side, 
blunt on the other. The malleability of the instrument allows it to 
be curved at will. To use this irrigating curette in the cleansing of 
the uterine canal, I proceed as follows : 

The patient being placed in the obstetrical position, after a vulvar 
and vaginal toilet, I grasp, under guidance of the index fmger, the 
anterior lip of the cervix, and, if necessary, the posterior, with 
a vulsellum. The uterus is then lowered by drawing on the 
vulsellum and by having an assistant support the fundus through 
the abdomen. The irrigating curette is now introduced into the 
uterus by guiding it with the finger. According to the intensity of 
the curetting that is desired, the uterine surface is scraped, from 
above downward, with the blunt side or with the sharp side of the 
instrument. A tour of the uterine cavity is thus made and then the 
cervix is treated in the same way. In terminating, a large quantity 
of liquid (two to three litres) is allowed to flow, without withdrawing 
the curette, to complete the cleansing of the uterine cavity and to 
insure the exit of all the detached debris. 

Made in this way, uterine cleansing, besides securing complete 
asepsis, presents a double advantage : 

First, that of facilitating the penetration of the instrument to the 
fundus of the uterus, for in drawing on the cervix the curve of the 
uterine canal is straightened (Fig. 308). 




Fig 308. — Uterus drawn to the vulva by the use of the vulsellum, 
CU, uterine circle; 01, internal orifice. 

Second, that of facilitating the return of the liquid and thus pre- 
venting its penetration into the peritonaeum through the tubes. The 
same mechanism which so easily allows the entrance of instruments 
removes all obstacles to the reflux of the liquid. 

The classic intra-uterine injection, copiously given, will suffice in 
a certain number of cases, but I believe it more prudent to have 
recourse at once to the perfected intra-uterine injection that I have 
described. 

Ahdominal medication. — Two measures, ice on the abdomen or a 
large vesicatory. 



268 Puerperal SepticcEmia. 

The ice is preferable. It is enclosed in a rubber bag and applied 
on the abdomen by interposing a double layer of flannel, to avoid 
echars from freezing. The sack is kept in place by a belt around 
the abdomen. The ice should be changed every two or three hours. 

A large vesicatory will replace the ice in cases of necessity. 

The ice, by lowering the temperature of the genital organs, retards 
the multiplication of the germs and impedes their penetration into 
the organism. Besides, it is a powerful sedative against the ab- 
dominal pain. 

The vesicatory acts in the same way by the revulsion that it causes* 
But its action is less salutary and less complete. 

Leeching and cupping has been advised in some cases. 

General medication. — Tonics and antithermics are the two princi- 
pal indications. The best tonics are alcohol, milk, if tolerated, and 
ether in subcutaneous injections, in cases of collapse. As anti- 
thermics, sulphate of quinine (1 gramme to 1.5 gramme) and anti- 
pyrine (1 to 2 grammes) are administered. 

I do not speak of the special indications which may occur in 
consequence of the formation of purulent collections (suppuration 
of the broad ligaments of the iliac fossae, etc.). Local treatment 
will be the same, then, as in suppuration of these regions produced 
by causes other than puerperal septicaemia. 



, Extra-Genital Diseases. 269 



CHAPTER XVII. 



PUERPERAL PATHOLOGY.— EXTRA-GENITAL 
LOCALIZED DISEASES. 

A. Nervous system. — A passing delirium sometimes occurs during 
labor if it is painful or prolonged. This disturbance of the cerebral 
function is due, without doubt, to the intensity of the painful phe- 
nomena. It disappears after accouchement. 

Under the influence of the puerperal state, much more often after 
dehvery than during pregnancy, there is observed a veritable 
insanity (mania or melancholia), of a variable prognosis, and which 
may persist after the cessation of the puerperal state. Mania is 
sometimes the consequence of eclampsia. Septicaemia does not ap- 
pear to play any pathological role here. It has been pretended that 
pregnancy may exercise a fortunate influence on an already existing 
mania. Alienation of puerperal cause does not require any special 
treatment. There exists no indication to provoke abortion or pre- 
mature accouchement. 

Various neuralgias, notably odontalgia, are produced or aroused 
by pregnancy. Treatment : to avoid any operation on the teeth 
during gestation ; general or local narcotics. 

Lumbo-abdominal neuralgia is especially manifest. It is due to 
the uterine contractions. Treatment : laudanum or viburnum, in- 
ternally; morphine in subcutaneous injections. 

Women often complain of cramps in the calves of the legs. 
During pregnancy the pains in these regions are due to the venous 
distention, and are relieved by the horizontal position or by gradual 
compression. During accouchement these pains sometimes take a 
great intensity, and are caused by the compression of the nerves 
supplying these regions. An energetic massage is the only means 
of producing some relief. 

Hemiplegias, paraplegias, paralyses, or partial pareses, may be 
observed during pregnancy, due to their usual causes, and more 
often to haemorrhages of the nervous system than to albuminuria. 

The influence of the puerperal state on hysteria is variable ac- 
cording to the woman. Hysterical attacks are, fortunately, rare 
during labor, for they singularly disturb the period of expulsion and 
of delivery of the appendages. In hysterical subjects hypnotism 
might be employed during the period of dilatation. During ex- 
pulsion it would be useless and sometimes dangerous. 



270 Extra-Genital Diseases. 

Epilepsy, although variously influenced by pregnancy, is most 
often benefited. The treatment by bromide of potassium, even in 
strong doses, is advised, for it presents no danger to the fcetus. 

Chorea may appear or reappear during pregnancy. Usually it 
persists to the moment of accouchement, when it assumes a great 
intensity. It most often ceases after labor. During pregnancy it 
should be treated by chloral, by bromide of potassium and by 
morphine. During labor, chloroform should be given to quiet tbe 
convulsions, in case of need. In some cases of grave chorea, digital 
dilatation of the cervix or induced expulsion will be indicated. 

B. Respiratory system. — Bronchitis with a particularly tenacious 
cough may favor or determine abortion. It requires the usual 
treatment. 

Pneumonia, occurring during pregnancy, causes premature ex- 
pulsion in about one-half the cases. The prognosis for the mother 
and for the pregnancy is serious in proportion as gestation is ad- 
vanced. It is impossible to say whether the premature expulsion 
of the ovum exercises a favorable or an unfavorable influence on the 
disease. The treatment should be the same as when pneumonia 
occurs without pregnancy. Antimonium may cause expulsion of 
the ovum, or contribute to the expulsion, but the gravity of the 
prognosis relegates this consideration to a secondary consideration. 
If the woman is in labor, accouchement should be terminated as 
promptly as possible. 

Pleurisy rarely exercises an unfortunate influence on the course 
of pregnancy and this disease does not seem to be aggravated by 
the existence of the puerperal state. The treatment is the same as 
if pregnancy did not exist. 

C. Circulatory system. —The heart, under the influence of preg- 
nancy and of accouchement, is subject to overwork which i3roduces 
an hypertrophy of the left side and a dilatation of the right side. 
Now, if this organ was diseased previous to conception, grave dis- 
orders may result. The puerperal state may be the cause of two 
varieties of cardiopaths : One, acute endocarditis, almost always 
occurs during the post-partum and is only a localization of puer- 
peral septicaemia; the other, subacute or chronic endocarditis, 
resulting from pregnancy, terminates in the definite formation of a 
valvular lesion. Besides these two varieties, the puerperal state 
causes myocarditis exceptionally, and fatty degeneratte frequently. 

Disease of the heart quite frequently causes abortion or premature 
delivery. The frequency of this premature expulsion varies ac- 
cording to the following results obtained by Porak : 





Frequency of Premature Expulsion. 


Maternal Mortality 


Aortic lesions 


25 per 100 


23 per 100 


Mitral lesions 


42 " - - 


- 45 " 


Complex lesions 


43 " - - 


50 " 



Extra-Genital Diseases. 271 

Treatment. — Preventive : For a cardiopath, dissuasion from mar- 
riage ; if married, no children ; if children, no lactation. Curative : 
The ordinary medical treatment, digitalis, milk, diuretics. In grave 
cases, provoked abortion or premature delivery may be indicated. 

The peripheral circulatory system is subject to varices in one- 
quarter of the primiparae and one-half of the multiparee. They 
sometimes begin with pregnancy, but are especially marked toward 
the middle or toward the end. The obstruction of the circulation 
produced by the development of the uterus, the augmentation in 
the quantity of blood during pregnancy and perhaps a reflex action 
arising from the uterus, explain their production. 

When the child succumbs during the course of pregnancy, the 
varices are effaced (Budin, Eivet). This is an interesting sign of 
the death of the foetus. Among the complications may be noted 
oedema, eczema, ulceration, phlebitis, and finally, rupture, which 
may give rise to fatal haemorrhage. Treatment : Eepose in the 
horizontal position ; moderate compression with an elastic bandage. 

The cervix or the vagina may become varicose but the vulva is 
the favorite seat of varices. The varices often rupture sponta- 
neously, or in consequence of a traumatism, and give rise to grave 
haemorrhages. Treatment: Horizontal repose. Slight compression. 
In case of rupture, digital compression, forci- pressure, ligature. 

Haemorrhoids seem independent of the varices of the lower limbs 
and of the genital organs. They are observed during pregnancy 
when the constipation is obstinate. Treatment: Laxatives, repose, 
baths, cold cataplasms, sedative suppositories, exceptionally surgical 
dilatation of the anal sphincter. 

Phlegmasia alba dolens. — Under this term has been designated 
venous coagulation of the lower limbs. The cause is, as we have 
seen in studying puerperal fever, sometimes a septicaemic phlebitis, 
sometimes a phlebitis, of an undetermined nature, but which seems, 
however, not to be related to septicaemia. Whiteness, hardness, and 
painfulness, are the three characters of the oedema produced by 
this affection. The onset usually takes place about the fifteenth 
day of post-partum. The duration is from one to three months. 
The length of the disease is due to the coagulation of the blood, the 
€lots absorbing slowly. It is very important to keep the patient in 
a recumbent position until the resorption and the disappearance of 
the clots, on account of the danger of pulmonary oedema and of 
sudden death. Treatment : In the beginning, quinine or anti- 
pyrine against the febrile element ; vesicatory on the painful points 
of the lower limbs ; to place the limb in a trough and envelop it in 
compresses soaked in a borated solution; to replace the moist 
dressing by a dry dressing (simple wrapping with cotton) as soon 
as the inflammation has disappeared, recognized by the cessation 
of the pain and fever; to keep the patient in a horizontal position 



272 Extra-Genital Diseases. 

until the danger from embolism has passed. The limb should be 
enclosed in an elastic bandage for about six months, or more if 
swelling follows when it is removed. 

D. Digestive system. — Pregnancy sometimes produces abundant 
salivation which is observed especially at the beginning, and which 
is rebellious to all treatment, except to atropine in the dose of a 
milligramme. 

Gingivitis occurs by preference in the second month of pregnancy* 
Care should be taken with the cleansing of the mouth and there 
should be applied on the free border of gums a solution composed 
of equal parts of spirits of cochlearia and of hydrate of chloral. 

The vomiting of pregnancy becomes g7'ave when it is capable of 
altering the general health of the woman. It is incoercihle when it 
resists the greater part of the usual methods employed to oppose 
them. A great number of procedures have been tried against in- 
coercible vomiting, sometimes in vain, sometimes with success, so 
that it is impossible to be exclusive. It is necessary to attempt, in 
turn, all the means advised until the efficacious agent is found, and 
if all fail to have recourse to the uterine treatment I shall indicate 
in terminating. It is important to distinguish the cases where 
there exists with pregnancy an affection capable of determining 
the incoercible vomiting from those in which all special setiological 
ideas are wanting. 

When there exists a casual disease the appropriate treatment will 
be directed to its removal. When there exists no appreciable cause 
the procedure then consists in successively attempting the various 
means enumerated as follows : 

1. Various remedies. — Variation in the aliments. Alcohol. Alka- 
lies. Ice internally. Milk diet. Purgatives. Emetics. Bismuth. 
Iodide or bromide of potassium. Valerianate of cerium. Oxalate 
of cerium. Lavage and gavage of the stomach. Nutritive enemas. 
Forced journeys. 

2. Sedatives. — Opiates. Hydrochlorate of cocaine. Hydrate of 
chloral. 

3. Excitants. — Inhalations of oxygen. Electricity. 

4. Revulsives. — Ether spray over the stomach. Ice on the epi- 
gastrium, or on the spine. Vesicatory or leeches on the epigastric 
region. 

5. Uterine treatment. — (a) Applications to the cervix of belladonna, 
of cocaine, of leeches. Cauterizations of nitrate of silver or with 
the thermo-cautery. (b) Digital dilatation of the cervix by Coper- 
man's method. The finger is introduced into the cervix to the in- 
ternal orifice, that is opened; then attempt is made to dilate the 
cervix by a circular movement of the finger, and to detach the mem- 
branes as far as possible. This method should only be attempted 



Extra- Genital Diseases. 



273 



if the preceding means fail, as it may cause abortion or premature 
labor, (c) Abortion and induced accouchement. Finally, in cases 
resisting all therapeutic measures and where life is threatened, we 
should have recourse to the induction of abortion or of accouchement 
by employing the measures that will be indicated later. 

Constipation is the rule during pregnancy. This will be combatted 
by the usual means, avoiding all energetic and drastic purgatives. 
Diarrhcea is the exception ; however it may become incoercible in 
some cases and determine abortion and even the death of the 
patient, without the autopsy revealing any lesion of the intestine 
that explains the gravity of the disease. 




FiG. 309, — Test for albumen with nitric acid. 

E. Ajypendagesofthe digestive system. — Hypertrophy of the thyroid 
is the rule during pregnancy. It diminishes after accouchement 
without resuming its former dimensions. Fatty degeneration of 
the liver is also the rule during pregnancy. Simple icterus may 
cause the death of the foetus or its premature expulsion. Grave 
icterus occurs with its usual symptoms. Pregnancy by the retard- 
ation that it imposes on combustion is also a great cause of hepatic 
coKc. 

F. Urinary system. — Albuminuria is not a disease but a symptom 
constituted by the presence of albumen in the urine. Its importance 
in the puerperal state is considerable on account of its frequency 
and of the danger of eclampsia that it threatens. Albuminuria is 
recognized by the examination of the urine. Among the different 
means of detecting its presence, we have the nitric acid test, which 



274 



Extra- Genital Diseases. 



is expeditious but not sensitive (Fig. 309) ; heat and nitric acid, 
which is more certain (Figs. 310 and 311), and Esbach's procedure. 
In the last method the reagent intended to precipitate the albumen 
is a mixture of nine volumes of picric acid with one volume of 
acetic acid. A tube specially graduated (Fig. 312 a) is filled with 
urine to U, and with the reagent to E. The mixture is made by 
closing the tube with the thumb and shaking. The tube is finally 
closed with a rubber cork and left for twenty-four hours. At the 
end of this time the lower graduation allows us to read the quantity 
of albumen deposited (Fig. 312 b) indicating the amount contained 
in a litre of urine. 




Fig. 211. — Test for albumen by the use of heat. 



Fig. 310. 



Albuminuria, either directly or through the complications that it 
produces (utero-placental haemorrhage), may obstruct the develop- 
ment of the ovum, cause the death of the foetus and prevent preg- 
nancy from arriving at normal term. Albuminuria also predisposes 
to the genital haemorrhages. But the result most to be feared is 
eclampsia which threatens the pregnant woman. 

The treatment will vary according to the variety of the albumin- 
uria. In the case of febrile, cachectic or cardiopathic albuminuria, 
the presence of albumen in the urine is only of secondary importance 
and the treatment should be directed against the casual affection. 
But if the albuminuria is of renal, or even simply of gravid origin, 
the vice of secretion produces a fear of eclampsia and the efforts- 



Extra- Genital Diseases. 



275 



mi^st be directed to the endeavor to re-establish elimination or to 
supplement it by other ways. The treatment then presents a close 
analogy with that of eclampsia, except that the minor therapeutic 
tripocl nere holds the preponderating importance. The minor tripod 
consists, as in eclampsia, of diuretics, purgatives and diaphoretics. 
With regard to the major tripod, bleeding will only be employed in 
exceptional cases and when eclampsia is imminent. Under anaes- 
thetics, Noeggerath has noted the beneficial influence of hydrate of 
chloral on albuminuria. This success should encourage its use. 
Uterine depletion consists of inducing abortion or accouchement, in 
very exceptional cases, when, in spite of the employment of the 
preceding measures, there is reason to fear the death of the patient 
or a fatal eclampsia. 



Fig. 312 — Esbach's graduated tubes, a, empty ; d, filled, 
the precipitate being deposited. 

G. Regions. — Pregnancy aggravates the majority of the cutaneous 
diseases. Under the influence of gestation an intense generalized 
pruritus may develop, sometimes without lesions, sometimes ac- 
companied by vesicles and pustules. Treatment : alkaline baths, 
lotions of cocaine solution. 

The result of traumatism during pregnancy is variable. In 
general, traumatism, accidental or operative, is dangerous, with re- 
gard to the interruption of pregnancy, in proportion as it approaches 
the genital sphere. In the union of fractures the formation of the 
callus is often retarded, but the cicatrization of wounds in general 
is not interrupted by pregnancy. 



276 



Extra-Genital Diseases. 




Fig 313 — Mammary bandage. 

An abscess of the breast is exceptional during pregnancy. It may 
be produced, however, under the influence of traumatism, of excori- 
ation, or of eczema of the nipple. There are no special therapeutic 
considerations. 




Fig, 314. — Mammary bandage applied. 

Hypertrophy, simple exaggeration of the normal increase due to 
the gravid state, may be observed. This hypertrophy exists some 
times to a very marked degree. After accouchement the breasts 
return to nearly normal size. Sometimes this regression is so slow 
that lactation is impossible. The various means of treatment that 
have been advised are ineffectual. It is necessary to be content 
with a simple support given by an appropriate bandage (Figs. 313 
and 314). 



Diseases of the Bony Pelvis. 277 



CHAPTER XVIII. 



DISEASES OF THE BONY PELVIS. 

A. Diseases of the articulations. 

I. Relaxation of the symphyses. — The three articulations which 
interrupt the pelvic ring are subject, during pregnancy, to a soften- 
ing of their tissues that, fortunately, corrects the rigidity of the 
pelvis in view of accouchement. This physiological state may become 
pathological by excess. The three symphyses, then, are subject to a 
veritable relaxation, more easily appreciable at the pubes than at 
the sacro-iliac articulations. This articular relaxation is manifested 
by two important symptoms : 

a. Functional iceakness. — The woman feels an increasing difficulty 
in walking. She waddles in walking. It seems to her as if the 
thighs could no longer sustain the pelvis. Walking sometimes 
becomes impossible. 

h. The pain relates to a general fatigue and to suffering at the 
articular interlines of the pelvis. Local pressure causes a most 
clear exacerbation. 

By examination two signs are found which confirm the diagnosis : 

1. The abnormal mobility oj the bones. — The woman being in the 
upright position, the finger in the vagina is brought into relation 
with the symphysis pubis. Then, when the patient raises the limbs 
alternately, an independent movement of the two articular surfaces 
is very clearly felt. 

2. Articular crepitation. — This crepitation, analogous to that met 
in an old arthritis, only rarely exists in relaxation of the symphyses. 
The relaxation generally begins at a variable period of the second 
half of pregnancy and is marked up to the moment of accouche- 
ment. Cure occurs after delivery but the relaxation sometimes 
persists a long time. The consolidation of the articulations may 
even remain incomplete. 

Eelaxation of the symphyses is a relatively frequent complication 
of the puerperal state, but it often remains unrecognized. The 
painful and functional disturbances of which it is the cause being 
simply and wrongly attributed to the pregnancy itself. An attentive 
exploration, based on the preceding signs, will permit an easy 
diagnosis. 

The only efficacious treatment of this affection consists in the 
application of a bandage, a double circle around the pelvis, giving 



278 Diseases of the Bony Pelvis. 

it artificial solidity. The best apparatus is Martin's belt, com- 
posed of a circle of steel, covered by soft material, which passes 
above the trochanters and buckles in front. This belt should be 
made to order and exactly molded to the contour of the body. 
Well made it is easily supported and overcomes the greater part of 
the inconveniences of relaxation of the symphyses. It should be 
worn until return of the articulations to their normal state. 

II. Inflaimnation of the articulations. — Inflammation of the pelvic 
symphyses may be produced in three principal conditions : 

1. In consequence of relaxation of the symphyses, the inflam- 
mation be3oming a complication. 

2. In consequence of rupture of an articulation any obstetrical 
traumatism (forceps, version, difficult labor) may act in the same 
way, even when it does not produce a complete rupture of the sym- 
physis attacked, and where it is confined to a simple contusion. 

3. Under the influence of the puerperal state ; an influence ad- 
mitted when no other cause can be found (perhaps of rheumatismal 
nature) . 

This arthritis, attacking one, two, or all three symphyses of the 
pelvis, is manifested by a fever of variable intensity and locally by 
pain and doughyness of the diseased articulation. When inflam- 
mation is a consequence of relaxation or of rupture the symptoms 
of these different affections are confused and make diagnosis more 
complicated. 

Termination takes place by cure, in a few days, or by transfor- 
mation into a chronic state, or by suppuration. 

The prognosis naturally varies according to the intensity of the 
disease. 

The treatment is the same as that of arthritis in general. It is 
useless to dwell on it here. Eepose and immobilization of the pelvis 
constitute its basis. 

III. Rupture of the symphyses. — When there is a disproportion 
between the size of the foetal head and the space presented by the 
pelvic i)assage, if the accoucheur (forceps, manual extraction) or 
the utero-abdominal contraction energetically force the exit of the 
child, there may result a fracture of the foetal cranium, or, mcje 
often, a rupture of one of the pelvic symphyses. 

The symphysis pubis is rarely affected. Usually it is one of the 
sacro-iliac symphyses that suffers. This is easily explained by the 
energetic pressure on the sacrum. 

At the moment of this rupture the woman feels an acute pain, a 
sensation of tearing ; the obstetrician perceives crepitation and the 
feeling of an obstacle suddenly overcome, analogous to that given 



Diseases of the Bony Pelvis. 



279 



by the passage of the head through the narrowed promonto-pubic 
diameter when it falls into the excavation. 

Articular rupture, which is only a pronounced sprain, terminates 
in inflammation. The consequences of the accident are those of 
arthritis with a veriable progress according to its intensity. The 
treatment is the same as that of arthritis. 




Fig. 315. — Normal pelvis. 




Fig. 316. — Antero-posterior section cf a normal pelvis. ♦ 

B. Pelvic deformities. — The normal conformation of the bony 
pelvis (Figs. 315, 316) has already been considered, it is useless to 
review it here. The pelvis is deformed whenever, by its confor- 
mation or by its direction, it deviates from the normal state. The 
pelvic deformities can be divided into four classes : 



280 Diseases of the Bony Pelvis, 

I. Deformities of amplitude. 

1. Pelvis too large. 

2. Pelvis too small. 

II. Deformities of length. 

1. Pelvis too long, too deep. 

2. Pelvis too short. 

III. Deformities of direction. 

1. Pelvis in anteversion. 

2. Pelvis in retroveision. 

3. Pelvis in lateroversion. 

lY. Deformation of continuity. 

1. The cleft pelvis. 

» 

We shall successively study : 

A. The pathological anatomy, that is, the conformation of 

the deformed pelvis and at the same time the aetiology 
and pathogeny. 

B. The symptomatology, that is, the symptoms produced during 

the puerperal state. 

C. The diagnosis. 

D. The prognosis. 

E. The management. 

A. Pathological anato^ny; ^Etiology; Pathogeny. — I. Deformities oj 
amplitude. — We shall not take into account the pelvis that is too 
large, for its importance in practice is nul. The narrowed pelvis, 
on the contrary, has a considerahle importance on account of its 
frequency and of the obstacle to accouchement. Below is the 
classification I shall follow in its study : 

A. Pelvis with simple deformity. 

1. Viciation by general disease (antero-posterior contraction by 

preference). 

/ % A i. 1. / I. u- 1 • \ r !• Tusto-minor. 
(a). AtrophyJ^atrophic pehas). I ^ ^riattened. 

" X' P- ' \^ 2- Flattened justo-minor. 

f I. Justo-minor. 

(b). Rachitis (rachitic pelvis). J 2. Flattened. 

Frequency, 6o per loo. j 3. Flattened justo minor. 

[ 4. Star-shaped, figure-of-eight, exostotic. 

(c). Osteomalacia (osteomalacic pelvis). ) 5, , _, 
Frequency, i per 100, J 

2. Viciation by local disease (transverse contraction by prefer- 

ence). 

(d). Sacro-iliac arthropathy (sacro-iliac f i. Simple ovular oblique pelvis, 
pelvis). Frequency, i per 100. \ 2. Double ovular oblique pelvis. 



Diseases of the Bony Pelvis, 



281 



(e). 



(f). 



Rachidian deviation (rachidian pelvis^ 
Frequency, lo per loo. 



Alteration of the lower limbs 
(crural pelvis). Frequency, 
5 per loo. 



r fWi 

V- twi 

( 2. With( 



1. Lordosic pelvis. 

2. Scoliotic pelvis. 

3. Cyphotic pelvis. 

With simple coxo-femoral luxation. 
With double coxo-femoral luxation, 
out luxation. 



3. Yiciation by invasion (irregular contraction). 

(g). Spondylolisthesis (vertebral pelvis). Frequency, i per 100. 
(h). Fractures (fractured pelvis) Frequency, i per 100. 
(i). Tumors (neoplastic pelvis). Frequency, i per 100. 

B. Pelvis ivitli complex deformity. 

Frequency nearly equal to that of simple deviations. 

A. Pelvis ivith simple deformity. 

(a). Atrophy. — Outside of rachitis, under an influence still unde- 
termined but in which heredity plays an important role, individuals 
are seen whose body, or sometimes only a part (head, thorax, 
pelvis) is subject to an arrest of development. This atrophy, when 
it relates to the female pelvis, produces the deviation that we now 
study. This form of deformed pelvis may present three types of 
deviation. 




Fig. 317. — Atrophic justo-minor pelvis. 

1. Justo-minor. — By this expression, that common usage has con- 
firmed, and that is opposed to a justo- major (generally enlarged 
pelvis), is designated a pelvis (Fig. 317) in which all the diameters 
have been subjected to a diminution, or rather to a want of develop- 
ment. It is a pelvis generally narrowed, with perfect form. 

2. Flattened (flattened atrophic pelvis). — This is also called 
Betschler's pelvis. Only the antero-posterior diameters are con- 
tracted, the transverse or oblique remaining normal or slightly 
enlarged. Let us take the preceding variety and push the sacrum 
forward toward the pubes, the curvature of the iliac bones is 



'Jb2 



Diseases of the Bony Pelvis. 



increased by this, while the transverse and oblique diameters un- 
dergo a certain augmentation (Fig. 318). 




Fig. 318. — Flattened atrophic pelvis. 

3. Flattened justo-minor. — Let us take a very i)ronounced justo- 
minor pelvis and, as before, push the sacrum forward. The result 
is the same, that is, diminution of the antero-posterior diameter, 
increase of the transverse and oblique. However, the latter, being 
primarily very narrow, cannot attain the normal dimensions and 
the pehis remains contracted in all its diameters, but with pre- 
dominence of contraction in the sacro-pubic direction (Fig. 319). 




Fig. 319. — Flattened atrophic justo-minor pelvis. 

(b) . Rachitis.— Thi^ disease, occurring during the first two or three 
years of life, is characterized by a disturbance of the nutrition, and 
especiaUy by a vicious evolution of the tissues which occurs with 
ossification. The bones, in place of having, from a normal calci- 
fication, their natural solidity, are soft and of little resistance, so 



Diseases of the Bony Pelvis. 



283 



that they curve and become deformel. Under the influence of 
rachitis pelvic deviations arise which have a great analogy with the 
preceding class although the varieties are more numerous. 

1. Justo-minor (rachitic justo-minor pelvis) — As in the case of an 
atrophic pelvis the lack of development affects all the pelvis. There 
is a difference, however, as the contraction is especially pronounced 
at the superior strait (Fig. 320). There is at this level an anular 
contraction, this expression being opposed to that of canaliculated, 
as applied to stenoses affecting the whole of the bony canal. 




Fig. 320. — Rachitic justo-minor pelvis. 

2. Flattened (flattened rachitic pelvis). — As in the atrophic pelvis, 
it is the projection of the sacrum, and especially of the promontory 
toward the center of the pelvis, that causes the antero-posterior 
flattening (Fig. 321), and particularly promonto-pubic, at the same 
time with a relative increase, sometimes actual, of the oblique and 
transverse diameters. The promonto-pubic contraction is the char- 
acterictic of the flattened rachitic pelvis. This variety is the most 
frequent of all the pelvic deformities. 




Fig, 321. — Flattened rachitic pelvis. 

3. Flattened justo-minor (flattened rachitic justo-minor pelvis). — 
This is a combination of the two preceding varieties, which causes 
a contraction of ah the diameters with predominence of the 



284 



Diseases of the Bony Pelvis, 



shortening of the antero-posterior (Fig. 322). As in all the varieties 
of the rachitic pelvis, the stenosis involves especially the superior 
strait. 




Fig. 322. — Flattened rachitic justo-minor pelvis. 

4. Rachitic pelvis (in star-shape, in figure-of-eight, exostotic). — I 
have grouped in the same paragraph these three varieties of the 
rachitic pelvis as they are seldom seen. 




Fig. 323. — Star-shaped rachitic pelvis, or pseudo osteomalacic. 

The star-shaped pelvis (Fig. 323), also called the pseudo osteo- 
malacic, presents a deformation analogous to that produced by 
concentric pressure on the sacrum and the femoral heads. The 
form of the pelvis is almost that of a star of three rays. 

The pelvis in the figure-of-eight (Fig. 324) is constituted by a 
very marked approach of the sacrum and the pubes toward each 
other. 

The exostotic pelvis is remarkable for a series of pointed spines, 
at the sacro-iliac symphysis, at the ilio-pectineal eminence, at the 
spine of the pubes (Fig. 325). These projections, depeloped under 



Diseases of the Bony Pelvis, 



285 



the influence of rachitis, are capable at the moment of accouchement 
of perforating the soft tissues. 

Whatever the variety of the rachitic pelvis, the sacrum may 
present independent incurvations that are interesting to observe. 




Frc. 324. — Rachitic figure-of-eight pelvis. 

In some cases the curve is but little modified. Sometimes it is 
exaggerated (Fig. 326). Then a false promontory is constituted. 
In other cases the curve may be straitened, or even directed 
contrary to the normal, the convexity facing the center of the pelvis. 
A. false promontory is also formed but in place of being lumbar, as 
before, it is sacral (Fig. 327) and found at the union of the first and 
second segment of the sacrum. 




Fig. 325. — Exostotic pelvis. 

(c.) Osteomalacia is a softening of the bony skeleton occurring 
during the adult period. It is analogous to rachitism, not in its 
lesions but in its results. It often takes its origin in pregnancy. 
This disease produces only one variety of pelvic deformity, the star- 
shaped pelvis (Fig. 328). 



286 



Diseases of the Bony Pelvis. 



(d). Sacro-iliac arthropathy.— J] ndei- the influence of an affection 
of the right or left sacro-iliac articulation, sometimes of both, an 
affection not yet well determined, but which appears to be in some 
cases a vice of conformation, in others an arthritis of tubercular 
nature or of early age, there is formed a sacro-iliac ankylosis, with 
atrophy and resorption of the contiguous regions of the ilium and 
of the sacrum. The result of this disease on the configuration of 
the pelvis will vary according as a single articulation or loth are 
attacked : 



TRUE 




Fig. 326. — Rachitic pelvis with false 
lumbar promontory. 



Fig. 327. — Rachitic pelvis with false 
sacral promontory. 



1. A single articulation attacked (simple ovular oblique pelvis or 
Naegele's pelvis). Unilateral sacro-iliac pelvis. — The sacrum in- 
clines from the ankylosed side. The diseased iliac bone inclines 
toward the center of the pelvis pushing the opposed ilium in the 
contrary direction, so that the symphysis pubis is carried toward the 
healthy side (Fig. 329). The superior strait takes the form of an 
oval with the long axis directed obliquely. The transverse and the 
oblique diameters are the most affected. The deviation equally 
affects the superior strait, the excavation and the median strait. 

2. Both articidations attacked (double oblique ovular pelvis, or 
Roberts' pelvis). Bilateral sacro-iliac pelvis. — The ankylosis, occur- 
ring on both sides, causes a transverse approach of the iliac bones 
toward each other, the pubic symphysis remaining median, and 
pelvis symmetrical. However, the analogy with the preceding form 
gives it the name of double oblique, although, properly speaking, it 
is not oblique. The contraction is especially transverse (Fig. 330). 



Diseases of the Bony Pelvis. 



287 



(e). Rachidian deviations. — We shall only take into question here 
the simple deformities produced by rachidian deviation exclusively. 




Fig. 328. — Osteomalacic pelvis. 




Fig. 329. — Simple oblique oval pelvis or Nsegele pelvis. 

1. Lordosic rachitic pelvis — Lordosis only affects the pelvis when 
it exists in the lumbar region, its most frequent seat. It does not 
act on the conformation of the pelvis, but simply on its inclination 
forward, which is marked (Fig. 331) ; there is pelvic anteversion. 



288 



Diseases of the Bony Pelvis, 



2. Scoliotic rachitic pelvis. — The action of scoliosis on the pelvis 
may be multiplied by a simple lateral inclination or by an actual 
deformity. When deformity is present there is flattening of the 
lateral half of the pelvis toward which the deviated lumbar column 
inclines (Fig. 332). 




Fig. 330. — Double oblique oval pelvis or Roberts' pelvis. 




Fig. 331. — Rachitic lordosic pelvis. 

3. Cyphotic rachitic j)elvis. — This vertebral deviation is capable of 
causing, either an inclination of the pelvis backward, elevating the 



Diseases of the Bony Pelvis, 



289 



symphysis pubis, approaching the plane of the superior- strait to the 
horizontal, or a special and characteristic deformity which gives the 
pelvis the form of a funnel (Fig. 333). 




Fig. 332. — Rachitic scoliotic pelvis. 




Fig. 333. — Rachitic cyphotic pelvis (funnel-shaped pelvis). 

(f). Alterations oftheloiver limbs. — From the special point of view 
that we occupy, it is important to establish two distinct categories, 
according as there is, or is not, a coxo-femoral luxation (simple or 
double), for this luxation causes a special deviation of the pelvis. 
We shall then study successively the crural pelvis with luxation and 
the crural pelvis without luxation, it being understood that the term 
luxation will here be applied exclusively to the hip joint. 

1. Crural x>elvis ivith luxation (ilio- femoral pelvis of Guenot). — A. 
Unilateral luxation. — We shall note here cases in which the luxation 



290 Diseases of the Bony Pelvis. 

is backward, that is, toward the external iliac fossa or the great 
sacro-sciatic notch; luxation forward being relatively much more 
rare and its reaction on the pelvis still undetermined. The ilium 
of the luxated side is atrophied (Fig. 334). The symphysis pubis 
is thrown toward the diseased side by the atrophy of the ilium. 




Fjg. 334, — Crural pelvis with unilateral luxation. 

The point of support for the head of the femur being displaced up- 
ward the ilium undergoes a swinging movement which draws the 
ischium away from the center of the pelvis. The result of this is 
to increase the dimensions of the transverse diameter of the median 
and of the inferior strait, while those of the same diameter of the 
superior strait remain normal or only slightly diminished. Uni- 
lateral luxation, especially, produces, then, a pelvic asymmetry, for 
the contraction which may result at the superior strait is but little 
marked. 

B. Bilateral luxation (Fig. 3*35). — The alterations, which have 
been described for one side of the pelvis, exist here on both sides 
alike. The two iliac bones have been subjected to a certain degree 
of atrophy and to a swinging movement which separates the two 
ischii. The result is a notable enlargement of the inferior and of 
the median strait, transversely and obliquely, and a corresponding 
contraction of the superior strait. The displacement of the two 
femoral heads backward also causes a pelvic anteversion. 

2. Crural pelvis ivithout luxation (Fig. 386). — The alterations of 
the lower limbs, which, besides coxo-femoral luxations, may cause 
pelvic deviations are numerous. I shall only cite some examples : 
Traumatic affections — fracture, resection, amputation. Spontane- 
ous affections — atrophy of a limb (congenital or acquired), various 
lesions of the articulations. These various alterations of the lower 



Diseases of the Bony Pelvis, 



291 



limbs only act on the pelvis when they occur before the fifteenth 
year. 

The pelvic deviations which result from different alterations are 
too varied and too little known to allow a systematic description. 
The two important ideas that it is necessary to retain are, that 
(1) the pelvis becomes asymmetrical; (2) one side is subject to 
flattening or to an atrophy of variable degree. 




Fig. 335. — Crural pelvis with bilateral laceration. 




Fig. 336. — Crural pelvis without luxatior. 

(g). Spondylizeme and spondylolisthesis (vertebral pelvis) . — Spondy- 
lizeme and spondylolisthesis are connected by a common point, the 
invasion of the pelvis by the lower or lumbar portion of the verte- 
bral column, but the cause and the nature of these two affections 
are different. 



292 



Diseases of the Bony Pelvis. 



Spondylizeme is characterized by bending forward of the spine. 
One or more of the diseased vertebrae become carious, weakened 
and demolished, and the contiguous part of the vertebral column, 
being no longer supported, falls toward the pelvis (Fig. 337). 
Spondylolisthesis is produced simply by a gliding of the last lumbar 
vertebra on the sacrum (Fig. 338). 




Fig. 337. — Spondylizematous pelvis. 




Fig. 338. — Spondylolisthesic pelvis. 

(h). Fractures {fractured pelvis) — A crushing of the pelvis having 
produced multiple fractures of the iliac bones and of the sacrum, 



Diseases of the Bony Pelvis, 



29^ 



these become the cause of very capricious deformities. The dif- 
ferent varieties cannot be made to conform to any systematic 
description. The pelvis is more or less invaded by a vicious reunion 
of the fragments (Fig. 339). 




Fig. 339. — Fractured pelvis. 

(i). Tumors {neoplastic pelvis) — The two varieties of tumors which 
may obstruct the pelvis are the exostoses (Fig. 340) and the osteo- 
sarcomata (341). 




Fig. 340 — Deformity from exostosis. 

B. Complex pelvic deformities. — It is impossible to describe here all 
the varied types created by the different combinations of deviation. 



294 



Diseases of the Bony Pelvis. 



Knowing the simple forms of deformity it is easy to recognize the 
composite varieties. There are, however, some which demand a few 
lines of explanation. These are : 




Fig. 341. — Deformity from osteo-sarcoma, 

1. The scolio-rachitic pelvis. — The rachitis simultaneously attacks 
the vertebral column, which it deviates, and the pelvis, which it de- 
forms. On the other hand, the pelvis may be subject to the action 
of both rachitis and scoliosis. The deviation is analogous to that 
met in the simple scoliotic pelvis but with the difference that the 
promontory is much more projecting and the flattening of the side 
attacked is more marked. 




Fig. 342. — Cypho-scoliotic pelvis. 

2. The cypho-rachitic pelvis. — Kachitis generally causes the pro- 
jection of the promontory forward, cyphosis, on the contrary, throws 



Diseases of the Bony Pelvis. 



295 



this same region backward in such a way that these two influences 
seem to reciprocally correct the deviation. But if the cyphosis 
and the rachitis are very pronounced there is, at the same time 
with the narrowing of the inferior pelvic region, a projection of the 
promontory, so that the pelvis is contracted antero-posteriorly at the 
superior strait, and especially, transversely at the median strait. 




Fig. 343. — Pelvis too long. 

3. The cypho- scoliotic pelvis — Cyphosis and scoliosis combining 
their action create a funnel-shaped pelvis, which is also asym- 
metrical. (Fig. 342). 




Fig. 344. — Pelvis too short. 

II. Deviations of length. — The dimensions of the height of the 
pelvis are sometimes exaggerated (pelvis too long) (Fig. 348) and 
sometimes less than normal (pelvis too short) (Fig. 344). These 
deviations are of small practical importance. The second facilitates 



296 



Diseases of the Bony Pelvis. 



accouchement and obstetrical intervention ; the first, on the contrary, 
renders these manoeuvres difficult. 




Fig. 345. — Pelvic anteversion. 

III. Deviations of direction. — These deviations are, in the majority 
of cases, the result of deviations of the vertebral column. 

1. Anteversion, the result of lumbar lordosis, is a lowering of the 
symphysis pubis, inclining the vulva backward and approaching 
the plane of the superior strait to the vertical (Fig. 345). With this 
inclination engagement of the foetus in the excavation is difficult. 




Fig. 346. — Pelvic retroversion. 

2. Retroversion (Fig. 346), the result of cyphosis, produces an 
effect contrary to that of anteversion. The vulva is directed for- 
ward and its upper part can be seen when the woman is erect 



Diseases of the Bony Pelvis, 



297 



and the thighs together, while in the normal state it is completely 
hidden in this attitude. 

3. Lateroversion (Fig. 347), or lateral inclination, is the usual con- 
sequence of scoliosis and of inequality of the length of the lower 
limbs. It influences the inclination of the uterus during pregnancy. 




Fig. 347. — Pelvic lateroversion. 

IV. Deviations of continuity. — Only one type of this deformity is 
known ; that is, the cleft pelvis of Litzmann (Fig. 348). 




Fig, 348.— Cleft pelvis. 

B. Symptomatology.— We shall study here the influence of 
the pelvic deformities on pregnancy and on accouchement. 



298 Diseases of the Bony Pelvis. 

1. Pregnancy. — Among the numerous accusations brought against 
th6 i^elvic deformities, only two are justified. The contraction of 
the superior strait impedes the engagement of the foetal part during 
the latter part of pregnancy. From this arises the practical advice 
to always think of the possibility of a pelvic deformaty when, in the 
vicinity of accouchement, especially in a primipara, the foetal head 
is still free at the superior strait. This default of engagement 
prevents the fixation of the foetus and thus facilitates the production 
of vicious presentations. 

2. Accouchement. — The default of engagement and the late en- 
gagement of the foetal part, favoring the premature rupture of the 
bag of waters, or the formation of a voluminous sac, interrupts the 
opening of the cervix. There is fear of transformation of the vertex 
into brow or face, of procidence of the cord, or of uterine rupture. 
In presentation of the vertex the head presents certain peculiarities 
of descent interesting to know. 

With a flattened pelvis, that is narrowed between the promontory 
and the pubes, the head, arrested at the superior strait, is i^laced 
transversely, then it inclines on its posterior parietal bone, rarely 
on its anterior; the posterior parietal protuberance passes around 
the promontory by a twisting movement, Avhich usually brings the 
parietal protuberance to the side opposed to where it is found pri- 
marily. Then the head passes the contracted superior strait by a 
twisting movement of the posterior parietal protuberance and by 
swinging the biparietal diameter. 

If there is a cyphotic pelvis, engagement, occurs with greater 
facility, disengagement, on the contrary, is difficult on account of 
the contraction of the median and of the inferior strait. The head, 
in particular, is often arrested at the level of the sciatic spines, 
where the projection is exaggerated by the pelvic deformity. 

It is impossible to study the descent of the head in all the vari- 
eties of pelvic deviations. Besides the details of these different 
mechanisms are not well known. 

When the head comes last, it may meet in the pelvic stenosis the 
same obstacle to its passage as when it presents first. 

In the viciated pelvis where the promontory forms a very marked 
projection (rachitic variety) the head, arrested at the superior strait, 
sometimes presents in the region which is in contact with the sacro- 
vertebral angle a more or less deep depression, that in exceptional 
cases becomes a fracture. 

C. Diagnosis (pelvimetry). — To arrive at the knowledge of the 
different pelvic deformities w^hich have been described it is necessary 
to measure the principal diameters of the pelvis, or, in other words, 
to practice pelvimetry. Pelvimetry may be instrumental or digital. 



Diseases of the Bony Pelvis. 



299 



1. Instrumental pelvimetry. — There exist a great number of pel- 
vimeters, some external, a variety of compass; others mixed, one 
hranch remaining on the exterior while the other penetrates into 
the genital organs, and finally, the internal variety (Fig. 349), that 
is used in the vagina to measure the distance which separates ihe 
pubic symphysis from the promontory. All these instruments have 
fallen into a just oblivion, dethroned and replaced by digital pel- 
vimetry. 




Fig. 349, — Pelvi-cephalometer of Budin. 

2. Digital pelvimetry may be external or internal. 

It is external when it relates to measurement of the bisischiatic 
diameter. The woman. being placed on the side, or in the genu- 
pectoral position, the two thumbs depressing the soft tissues seek 
the internal surface of the ischium on each side in contact with 
which they are maintained while an assistant measures the distance 
separating the two exploring fingers. To this measure there is 
added the part occupied by the soft tissues, one to two centimetres. 

In internal digital pelvimetry, by the introduction of the index 
finger (Fig. S^O), of the index and middle finger (Fig. 351), or of 
four fingers (Fig. 352), one can measure the minimum promonto- 
pubic diameter and the sacro-pubic of the median strait. Only 
one finger should be used, as often as possible, and it is this uni- 
digital procedure that I shall describe in detail, for it should be 
familiar to every physician. 

Minimum promonto -pubic diameter. — The index finger introduced 
into the vagina is directed toward the promontory. When, with a 
perinseum of median resistance, the finger cannot arrive at the 
promontory, the pelvis is normal (with regard to the promonto-pubic 



300 



Diseases of the Bony Pelvis. 



diameter, the one most often shortened) ; when, on the contrary ^ 
the finger can attain this point there is deformity. 




Fig. 350. — Internal unidigital pelvimetry. 

Practical -conclusion : Whenever a pregnant woman is examined 
in view of her accouchement, especially if a primipara, it should 
never be forgotten in digital examination to seek the promontory. 
If it cannot be reached, the chances are that the pelvis is normal, 
for out of ten cases of pelvic deformity it can be admitted that nine 
attack the promonto-pubic diameter. 




Fig. 351. — Internal bidigital pelvimetry. 

When the promontory is attained, the radial border of the hand 
is applied against the inferior part of the symphysis pubis and with 
the index finger of the other hand the limit of the symphysis is^ 
marked, taking care to determine this point as exactly as possible. 
An assistant measures the distance which separates the extremity 
of the index finger from the point marked and the length of the 
promonto-subpubic diameter is thus known. 



Diseases of the Bony Pelvis. 301 

Now this diameter (in the normal state twelve centimeters) is 
generally one centimetre greater than the promonto-suprapubic 
and one and one -half centimetres greater than the minimum pro- 
monto-pubic It is necessary then to subtract one and one-half 
centimeters from the length found to obtain the minimum pro- 
monto-pubic diameter. 




Fig. 352, — Internal quadridigital pelvimetry. 

When the promontory is relatively high, or when it is desired to 
measure a false lumbar promontory, two centimetres are subtracted. 
In the contrary case, and with a false sacral promontory, only one 
centimetre, for the difference between the promonto- subpubic and 
the minimum pubic diameters is exaggerated as much more as the 
promontory is elevated and diminishes as it is lowered (Figs. 353 
and 354). 

Siibsacro-suhpiihic diameter. — We proceed as above, seeking, by 
means of movements given to the coccyx, the sacro-coccygeal articu- 
lation. The distance obtained to the edge of the pubes is measured 
on the exploring finger; this is, without reduction, the subsacro- 
subpubic diameter. 

Knowing these elements of pelvimetry we can study the diagnosis 
of the pelvic deformities. Here there will only be in question the 
simple contractions, as I shall eliminate all the other viciations, 
their importance being secondary. 

It will be easy to suspect and to recognize the atrophic pelvis in a 
dwarf, the conformation of the woman will put us on the track of 
the diagnosis. But if the conformation be normal, the vagino-pelvic 
exploration alone will lead to the diagnosis. Digital pelvimetry will 
give the dimensions of the antero-posterior diameters and especially 
the minimum promonto-pubic. For the transverse dimensions, it 
is necessary to be content with an approximate valuation. 



302 



Diseases oj the Bony Pelvis, 




Fig. 353. — Promonto-pubic diameters (Budin). S, sacrum; Pr, promontory ; Sp, 
promonto-subpubic diameter, twelve centimetres; Pu, promonto-suprapubic diameter, 
eleven centimetres; m, minimum promonto-pubic diameter, ten and a-half centimetres. 




Fig. 354. — Variations of promonto-pubic diameters, according to the relative 
height of the symphysis pubis and of the promontory (Budin). 

The rachitic pelvis will often he devined from the general aspect 
of the woman, small figure, large head, face sometimes asym- 
metrical, teeth bad, thorax prominent, deviation of the vertebral 
column, alteration in the curvature of the lower limbs, finally, walk- 
ing will have been late, at two or three years of age instead of a year. 



Diseases of the Bony Pelvis. 303 

Direct examination mil permit completion of the diagnosis, and will 
afford recognition of the variety and degree of the rachitic deviation. 
The three types of the atrophic pelvis will only be distinguished 
from the three corresponding varieties of the rachitic pelvis by the 
aetiology (rachitis exists in the second case while there is no trace of 
it in the first). In general the degree of viciation is relatively slight 
in the atrophic pelvis wliile it may be very pronounced in the 
rachitic. 

The osteomalacic pelvis, besides the history which may throw 
some light on the causal disease, is recognized by its special form. 
The projection constituted by the symphysis pubis and the osseous 
defile which exists behind it are characteristic of the osteomalacic 
pelvis. 

The sacro-iliac pelvis is recognized by the marked flattening of 
one or of both sides of the pelvis, with absence of cause with regard 
to the vertebral column and the lower limbs. 

The rachitic, lordosic, scoliotic or cyphotic pehis will be noted by 
the spinal deviation which thus serves as a guide. The diagnosis 
will be controlled and verified by direct exploration. 

The crural pelvis will be sought in cases of alteration of the lower 
limbs. Its diagnosis is of secondary importance, for it is rare that 
the deviation is marked. 

I only mention the diagnosis of the vertebral, fractured, and neo- 
plastic pelvis, as these varieties can be considered as exceptions. 

D. Prognosis. — The prognosis for the mother and for the child 
wiU vary essentially with the degree of the pelvic deformity. 

A contraction of a few millimetres is without importance. 

A more marked contraction, two, three, to four centimetres, for 
example, becomes much more serious, for it may necessitate more 
or less dangerous interventions (induced accouchement, forceps, 
version, embryotomy): 

A very pronounced contraction renders the prognosis exceedingly 
grave, for there is often no other means of delivering the woman 
except Caesarian section. 

In the same woman the prognosis of the deformity becomes more 
serious as the number of pregnancies become greater. Thus it 
often happens that a pelvic deformity does not cause any difficulty 
in the first and second accouchement but becomes a serious obstacle 
in the third and fourth. This increasing gravity is probably due to 
the increasing volume of the foetus at each new gestation. 

E. Management. — In obstetrical language there are currently 
employed the expressions, pelvis of eight centimetres, pelvis of six 
centimetres, etc. By this we mean a pelvis the shortest diameter of 
which measures eight centimetres, six centimetres, etc. A normal 



304 Diseases of the Bony Pelvis. 

pelvis is consequently a pelvis of ten centimetres. The degree of 
viciation is quite variable, but a pelvis of less than five centimetres 
is exceptional. The promonto-pubic diameter, being most often 
subject to deviation, is that which usually gives the figure to the 
pelvis. 

The foetus which must pass through the contracted pelvis should 
have, during accouchement, the head so placed that the antero- 
posterior cephalic diameters correspond to the largest space of the 
pehds, the most narrow pelvic diameter being reserved for the trans- 
verse, the biparietal. 

Now the biparietal measures at the end of the sixth month, six 
centimetres; seventh month, seven centimetres; eighth month, 
eight centimetres ; ninth month, nine centimetres. 

A pelvis of nine would permit accouchement, then, at term, a 
pelvis of eight at eight months ; of seven at seven months ; six at six 
months. Six complete months being the minimum term for the 
viability of the child, it will be seen that below a pelvis of six centi- 
metres it will be impossible to deliver a woman of a viable child by 
the natural passages. 

With these preliminaries let us study the conduct to be followed. 
We have five points to examine according as we are asked advice 
for a 

a. Young girl to marry. 

b. Married woman not pregnant. 

c. Pregnant woman. 

d. Woman in labor. 

e. Special cases. 

a. Young girl to marry. — If there exists a pelvic deformity local 
examination will recognize : 

Pelvis below six centimetres, no marriage, for except by Cseserian 
section it will be impossible for the woman to have a viable child; 

Pelvis of six to nine centimetres, marriage is possible, but the 
necessity of inducing early accouchement will be foreseen. 

Pelvis above nine centimetres, marriage is possible. Accouche- 
ment may take place at term but it should be explained that it may 
be difficult. 

b. Married ivoman not pregnant. — Pelvis below six centimetres, no 
pregnancy. 

Pelvis of six to nine centimetres, pregnancy possible, but neces- 
sity of inducing accouchement before term. 

Pelvis above nine centimetres, pregnancy can go to term, but on 
account of the possible difficulties accouchement demands special 
care. 



Diseases of the Bony Pelvis. 305 

€. Pregnant woman.^-Thvee circumstances may present : 

1. Woman and child normally healthy : 

Pelvis below six centimetres, to induce abortion, unless the woman 
demands Caesarian section at term. 

Pelvis from six to nine centimetres, to induce accouchement at a 
date indicated by the degree of contraction. 

Pelvis of six centimetres at six months (beginning of the seventh 
month) ; pelvis of seven centimetres at seven months ; pelvis of 
eight centimetres at eight months. 

•2„ Woman healthy and child dead. — No intervention is necessary. 
Await the spontaneous appearance of labor. 

3. Woman unhealthy, child healthy. — If the disease affecting the 
woman is without gravity the management remains the same as if 
she were healthy. But if the disease is grave, fatal (cancer, ad- 
vanced tuberculosis) ; the child's life is to be regarded above all, the 
woman being condemned. In such cases the physician will be 
authorized to allow pregnancy to go to term and to perform 
Caesarian section. 

d. Woman in labor. — Three circumstances may be present : 

1. Accouchement may be spontaneous ; 

2. Or, it will be necessary to resort to forceps or to version, 
interventions of the first degree ; 

3. Or, as a last resource, to perform embryotomy or hysterotomy, 
interventions of the second degree. 

Parallel hetiveen forceps and version* — The parallel between these 
two operations, employed in the case of pelvic deformity, has given 
rise to long discussions. In intervening we especially have in view 
the passage of the foetal head. Now, on the manikin, with the 
same degree of pelvic stenosis, the extraction of the head last 
(version) is incontestably more easy than first, with the forceps. 

It is the same in a living woman with a dead child, on account of 
ihe mobility allowed the head by the hands and of the possibility 
of giving it different movements that the forceps do not permit. 

But with a Hving child we meet a new element, the life of the 
child. 

By the aid of the forceps (head first) traction can be made during 
a half- hour, and even more, and still a living child may be delivered. 
With version if the head, being last, is not extracted in less than 
five minutes the death of the child is assured. 

Version having the greatest difficulty in the extraction of the head 
and forceps exposing less to the death of the foetus, it is very diffi- 
cult to decide categorically between these two modes of intervention. 

Version seems preferable, however, in presentations other than 
those of the vertex (simple extraction in presentation of the breech). 



306 Diseases of the Bony Pelvis, 

The forceps, on the contrary, will be better in the majority of pre- 
sentations of the vertex, unless the head is very high, or except 
when there is procidence of a limb or of the cord or any analogous 
condition rendering the application of the instrument difficult. 

Parallel between hysterotomy and embryotomy. — 1 shall only pre- 
sent a resume of this subject. 

A. Mother healthy, child dead or condemned. 

When manual extraction or by the forceps is impossible, 
recourse to embryotomy. Hysterotomy will only be in- 
dicated when embryotomy is not practical on account of 
the degree of pelvic contraction. 

B. Mother dying or condemned, child healthy. 

Hysterotomy will here be preferable to embryotomy. 

C. Both mother and child healthy. 

1. Pelvis about nine centimetres. 

Territory of manual extraction or of the forceps. 
Possible invasion of embryotomy. 

2. Pelvis seven to nine centimetres. 

Territory of embryotomy. 
, Possible invasion of manual extraction or of the forceps, 
which should always be previously attempted. 

3. Pelvis of five to seven centimetres. 

Territory common to hysterotomy and to embryotomy. 
The choice should be in part left to the woman, 
leaving her free to expose herself or not to save her 
child. 

4. Pelvis below five centimetres. 

Territory of embryotomy. 

e. Special cases. — Certain pelvic deformities, for example, osteo- 
malacia may modify the line of conduct previously traced. In 
osteomalacia the pelvic bones may present, when the disease is 
recent, a certain suppleness which allows a relative facility of ac- 
couchement. 

In a general manner, the narrowing of the median strait is less 
grave than that of the superior, for the foetal head being less distant 
intervention becomes easier. 

In the same way a multiple pregnancy, monstrosities, etc., create 
special conditions, into the detail of which it is impossible to enter. 



Diseases of the Genital System. 307 



CHAPTER XIX. 



DISEASES OF THE GENITAL SYSTEM AND ITS 
DEPENDENCIES.— GENITAL DYSTOCIA. 

1. Narroivness and rigidity of the vidva are especially observed in 
women first becoming pregnant late in life, or in consequence of 
morbid processes having caused local modifications of the external 
genital organs. Treatment : Prolonged bath during labor ; forceps 
or manual extraction ; recourse to vulvar incisions only when abso- 
solutely necessary. 

2. Hymen. — Vaginismus. — The persistence of the hymen after 
coitus, or rather the resistence of the ring surrounding it, some- 
times obstructs the exit of the foetus. The contractions of the 
constrictor muscle of the vulva or of the levator ani may also be a 
cause of dystocia. Treatment : Chloroform in a dose sufiicient to 
cause muscular relaxation; forceps or manual extraction ; incisions 
rarely necessary. 

3. Vices of vulvar conformation. — Cicatrices. — The anomalies of the 
vulva and cicatrices in consequence of traumatism, gangrene, soft 
chancres, etc., may impede ampliation of this portion of the genital 
organs and obstruct expulsion. There sometimes exists an anomaly 
in the situation of the vulva, too far forward or backward ; the first 
obstructs accouchement, the second facilitates it. In difficult cases 
the treatment is the same as for vulvar narrowness. 

4. Tumors. — Vegetations, hypertrophic mucous plaques, cancer, 
oedema causing a tumefaction that is sometimes enormous, consti- 
tutes dystocic causes of variable importance. Treatment : Manual 
or forceps extraction, as slow as possible, to avoid great vulvar 
lacerations. 

5. Vices of conformation of the vagina. — Cicatrices. — Besides du- 
plicity there may exist in the vagina transverse bands, sometimes 
a veritable diaphragm of congenital origin, or cicatrices of variable 
resistance, consecutive to the traumatisms of previous accouche- 
ment. Treatment : simple expectation in slight cases. Prolonged 
hot injections, application in the vagina of a rubber dilator, vaginal 
massage, incisions, manual or forceps extraction. 

6. Vaginal prolapsus, unless accompanied by a marked degree of 
uterine descent, is of small importance; how^ever, it exposes to 
gangrene of the vaginal fold projecting through the vulva when the 
head remains too long at the perinseum. Treatment : sustain the 
vaginal fold with the fingers. Terminate the accouchement at need 



308 Diseases of the Genital System. 

by the forceps or by manual extraction, having the vagina sustained 
by an assistant in the meantime. 

7. Tumors, — Thrombus, — Cysts of the vagina are rarely large 
enough to cause dystocia. The most important tumor of the vagina, 
for dystocia, is thi'ombus. This interstitial haemorrhage results from 
the rupture of a normal vein, but most often is produced by the 
rupture of a varicose vein. It is exceptional before accouchement, 
rare during labor, and most frequent after delivery. Treatment : 
to abstain as much as possible ; during pregnancy horizontal repose ; 
during labor, to terminate the accouchement as soon as possible, and 
only to incise the tumor when it opposes an absolute obstacle to the 
passage of the foetus. 

8. Resistance and oedema of the perinceum. — Eecognize the same 
causes as for these conditions of the vulva and require the same 
treatment. Perinaeal lacerations have already been considered. 

9. Obliteration of the cervix, — Agglutination of the lips of the ex- 
ternal orifice is without importance and gives way, without difficulty, 
to the action of uterine contraction. Fibrous obliteration, affecting 
the internal or the external os in consequence of ulcerations or 
caustic treatment, prevents the opening of the cervix. Tliis ob- 
literation may be confused with a simple deviation of the cervix and 
it demands careful exploration, under anaesthesia, if necessary. If 
the obliteration of the cervix is real a cervical incision will be made 
in the supposed site of the external os, controlling its extent- by the 
use of the speculum and vision. This opening is slowly enlarged, 
by multiple incisions, taking care not to wound the foetus. 

10. Rigidity of the cervix has been divided into pathological, spas- 
modic, and anatomical. 

Pathological, that is to say, caused by the existence of a cervical 
affection, parenchymatous metritis, cicatrices, fibromata, cancer. 

Spasmodic, due to muscular contraction of the cervix, and es- 
pecially of the inferior segment of the uterus, for the latter is richer 
in muscular fibres than the cervix. The cervix and the inferior 
segment are painful, sensitive to pressure, hot, thin and tense if 
effacement is completed. The uterine contractions are irregular. 
Often there is fever. The dilatation of the cervix remains station- 
ary or only advances very little, in spite of the acute sufferings of 
the woman. This spasmodic rigidity is due to too repeated ex- 
plorations, to manoeuvers intended to dilate the cervix, to any cause 
capable of irritating the cervix, but especially to the administration 
of ergot during labor. Treatment : chloral and chloroform, as for 
obstetrical anaesthesia. If the spasmodic rigidity does not yield to 
these measures it is on account of association with a pathological 
state. 



Diseases of the Genital System. 309 

Anatomical. — This rigidity is due to a special state of the cervix 
(and not of the inferior segment, as in the spasmodic) which im< 
pedes the opening and the dilatation of the uterine orifice. This 
rigidity may be relative, that is, the uterine contractions are not 
sufficient to vanquish the normal resistance of the cervix; this is a 
false rigidity that must be eliminated from this class, as it only in- 
cludes real or absolute rigidity in which the uterine contractions 
are normal. 

Contrary to the spasmodic variety, the effaced cervix is hard, 
thick, resisting, not painful and gives the sensation of leather 
soaked in grease. The uterine contractions are very painful, with 
lumbar predominance of the pain. The dilatation is effected with 
an extreme slowness and may last several days. 

The cause of this rigidity is the incomplete softening of the 
cervix under the influence of pregnancy. Labor occurs before the 
puerperal state has sufficiently prepared the cervical portion for 
the distention to which it is subjected, thus premature accouche- 
ment is a frequent cause. 

Treatment. — Procedures of the first cZe^r^e.— Prolonged baths with 
vaginal injections in the bath. Irrigations of hot water. Borated 
glycerine or vaseline applied to the cervix in large quantities. 
Chloral applications to diminish the pain. Dilating rubber-bag in- 
troduced into the cervix. 

Procedures of the second degree {only exceptionally employed and in 
case of absolute necessity). — Dilatation by a metallic instrument (Fig. 
355). Multiple incisions (dangerous). Manual extraction or ex- 
traction with the forceps before complete dilatation, taking care to 
make very gentle and prolonged tractions during a half hour, three 
quarters of an hour, an hour or even more, during which the woman 
is kept under the influence of angesthesia. 

11. Deviations of the cervix. — The cervix or the external orifice 
after effacement may be deviated forward, backward or laterally, 
in the direction of the different vaginal culs-de-sac. The cause is 
either in the inclination of the body of the uterus, the cervix being 
carried in the inverse direction, or in the unequal development of 
the inferior segment of the organ. Deviation backward and to the 
left is normal. In the pathological state it is the exaggeration of 
this deviation that is most often observed. The treatment is nul 
during pregnancy. At the moment of labor the deviation is cor- 
rected by the position of the woman or by drawing on the external 
orifice with the hooked finger to replace it in the normal position. 

12. Tumors of the cervix uteri. — (Edema occurring during ac- 
couchement is sometimes localized in a segment of the cervix and 
sometimes generalized. It requires no especial treatment. Simple 
hypertrophy is exceptionally a cause of dystocia. Vegetations, 



310 



Diseases of the Genital System. 



abscess and thrombus are pathological varieties. The fibromata 
will be studied with those of the body. Cancer, on account of its 
importance, merits a description as to management. 

Management. — Before conception, advise avoidance of pregnancy 
in an absolute manner. 

During jpregnancy. — Simple expectation with treatment of the 
pains and haemorrhages by the usual measures, unless the mother 
is menaced by death, in which case we have recourse, if the child is 
living and viable, to induced labor, or to Caesarian section before or 
after death. Amputation of the cancerous cervix and ablation of 
the whole uterus have been proposed and practiced but these op- 
erations are not to be advised any more than curetting and the 
actual cautery ( ?) as palliatives. 





Fig. 355. — Metallic dilator with six blades. 

During labor. — Incomplete dilatation. — a. While dilatation is pro- 
gressing, whatever its slowness, expectation is the best conduct un- 
less a pressing danger menaces the mother or the child. If the 
dilatation is stationary, if the mother or the child is in peril, it ia 



Diseases of the Genital System, 



311 



neeesriary to terminate accouchement artificially. With a dead 
child, or when its chances of life are very small, embryotomy should 
be resorted to as much as possible. With a living child, manual 
extraction or the forceps will be attempted if the dilatation is suf- 
ficient. If the dilation is insufficient to attempt this intervention, 
Caesarian section should be performed without hesitation. In some 
cases the extent of the cancerous invasion allows us to foresee the 
impossibility of dilatation of the cervix and the necessity for a 
Caesarian operation. 

(b). If dilatation is complete or a most incomplete, extraction will 
be made as soon as possible by the usual methods. If a serious 
haemorrhage follows after delivery utero-vaginal tamponnement is 
the preferable treatment. 








Fig. 356. 

Heart-shaped 



Fig. 357. 

Divided uterus. 



Fig. 358. 

Double uterus. 



Fig. 359. 

Double uterus and 
vagina divided. 



Fig. 360. 

Double uterus 
and vagina. 



13. Vices of conformation of the uterus. — These are constituted by 
incomplete fusion of Muller's canals. They are of various degrees 
(Figs. 356-360). 

These anomalies of conformation may be the cause of vicious 
presentations. They expose to uterine rupture and render inter- 
ventions difficult. Their management does not present any con- 
sideration of special importance. 

14. Anomalies of uterine contractions. — There may be exaggeration, 
weakness, or perversion of uterine contractions. 

Exaggeration in intensity, which exposes to rupture of the uterus, 
or to laceration of the perinaeum, will be quieted by the use of 
chloral and of chloroform. 

Weakening of the contractions, leading to uterine inertia during 
labor or delivery, is a state frequently observed, but which is 
usually intermittent and passing. It is most often produced by 
exaggerated distention of the uterus, by the death of the fcetus, by 
the length of labor or by certain acute moral impressions in 
nervous women. 

Uterine inertia, while grave after delivery, has usually no other 
inconvenience during labor than that of prolonging accouchement. 
During labor, to wait will generally be the better plan. If not, 



312 



Diseases of the Genital System. 



there are several measures which often succeed. They are : To 
modify the position of the woman, to make her rise and walk when 
she is lying down. To apply a rubber bag in the vagina. Hot 
vaginal injection carried up to the cervix. Sulphate of quinine 
0.50 to one gramme. Interrupted current: of electricity to the 
uterus. To practice rupture of the membranes when the dilatation 
has passed three finger's breadths, when the presentation is normal 
and the head deeply engaged. Never forget ergot at this moment. 
Perversions of the contractions is manifested in their irregularity 
or by their permanence in uterine tetanus. Chloroform or chloral 
usually re-establishes their normal intermittence. 




Fig. 361. — Retrodeviation of the gravid uterus (Schatz). Ve, bladder; 

Ur, urethra; A, anus. 

15. Uterine deviations. — At the end of pregnancy, the body of the 
uterus is often deviated forward, when previous gestations have 
weakened the abdominal wall and produced a more or less pro- 
nounced eventration. An appropriate belt and, during accouche- 
ment, the horizontal decubitus is sufficient to correct this deviation. 
Lateral deviations are rarely causes of dystocia. They will be 
remedied by the position of the woman. The most important dis- 
placement, on account of the disturbances it is capable of causing, 
is retrodeviation (Fig. 361). The beginning of a retrodeviation is 
sometimes slow and insidious, sometimes sudden in consequence 



Diseases of the Genital System. 



31S 



of an effort or a fall. - The most important symptom marking retro- 
deviation is the retention of urine, which may be complete or in- 
complete. The rectal compression by the body of the uterus causes 
an obstinate constipation. The pressure of the uterus on the 
perinaeum produces a sensation of weight that is sometimes very 
painful. 




9 



First month. 



Fig. 362. — A, uterus free ; B, uterus incarcerated. 

Second month, Third month. Fourth month. 





Fig. 363.— Retrodeviation of conception. Spontaneous reduction at fourth month. 







Fig. 364. — Retrodeviation of conception. Incarceration at the fourth month. 








G> 




Fig. 365.— Uterus normal at conception, inclining progressively backward 
and incarcerated the fourth month. 







& 



Fig. 366. — Uterus normal at conception, inclining suddenly backward 
at the fourth month and becoming incarcerated. 



314 



Diseases of the Genital System. 



It is important in the evolution of retrodeviation to distinguish 
two periods or states : First, the period during which the uterus, 
not yet large, may be replaced in its normal position mth relative 
facility ; second, the period of incarceration or impaction, during 
which the uterus, now too large, cannot swing in the pelvic 
excavation and is found imprisoned. The period of incarceration 
is produced at the beginning of the fourth month of pregnancy 
(Figs. 362-366). 




Fig. 367. — Sacciform dilatation (Oldham). 

If the reduction of the retrodeviation takes place before incar- 
ceration the disturbances produced by the displacement are few. 
But at the moment when incarceration is produced important 
conditions arise which may terminate in various ways : 

a. Terminatiomvith regard to the deviatiori. — There may be ter- 
mination in spontaneous or induced abortion. When abortion does 
not occur there may be : 

1. Reduction in consequence of repeated catheterism or of a 
special intervention intended to return the uterus to place. 

2. Semi-reduction {sacciform dilatation) (Fig. 367). — This is pro- 
duced by progressive development of the wall of the uterus toward 
the abdomen (Fig. 368). This variety should be distinguished in a 
pathogenetic point of ^iew from that produced at the end of preg- 
nancy by ampliation of the posterior inferior segment of the uterus 
(Fig. 369). 



Diseases of the Genital System, 



315 



3. No reduction. — The child dies and abortion is produced after a 
variable time. . 

h. Termination tvith regard to the patient. — Cure after reduction or 
abortion. Death may be produced before or after reduction, by 
septicaemia, by gangrenous cystitis, by rupture of the posterior wall 
of the vagina, of the rectum, and of the perinseum, or by a renal 
complication. 





Fig. 368. — Sacciform dilatation 
following retrodeviation. 



Fig. 369. — Sacciform dilatation without 
previous retrodeviation. 



Treatment. — When incarceration does not exist attempt should be 
made to replace the uterus by slight pressure with the finger in the 
posterior cul-de-sac. For the same purpose the patient is ordered 
to assume the genu-pectoral position for twenty minutes every 
morning and night. When incarceration exists there are three 
methods to follow, expectation, manual or instrumental reduction, 
induced abortion. 

1. Expectation. — Simple expectation, aided by regular cathe- 
ierism, three times a day, is sufficient in the majority of cases to 
cause spontaneous reduction, in eight to fifteen days. Thus, except 
in serious accidents, this is the method to follow. But the necessity 
of rectal evacuations should not be forgotten. 

2. Reduction. — Manual or digital reduction will be attempted with 
the woman in the dorsal, lateral, or genu-pectoral position. In 
difficult cases chloroform should be employed. A prolonged bath 
mil be favorable as a preparation for attempts at reduction. Some- 
times the introduction of a rubber bag into the rectum, leaving it 
inflated for twenty-four hours, causes gradual reduction. 

3. Induced abortion. — In cases where reduction is impossible and 
where grave symptoms necessitate prompt intervention, abortion 
should be induced at once. 



316 



Diseases of the Genital System. 



16. Uterine prolapsus. — Complete or incomplete prolapsus may 
exist at any period of term (Fig. 370). Treatment: Reduction of 
the uterus vrith its contents ; if this is impossible, previous evacu- 
ation (induced abortion) with final reduction. 




Vagina 



•UlccratioiK 



Fig. 370. — Prolapsus of the gravid uterus (Budin). 

17. Uterine ruptures. — Uterine ruptures may be divided : 

In view of the situation, into : 

1. Intra- vaginal (lacerations). 

2. Supra-vaginal, affecting the cervix, the isthmus or the body 
(this variety only will be taken under consideration here). 

In view of the degree, into : 

1. Incomplete. — Peritonaeum intact. 

a. Intra-muscular. — Simple separation, not attacking the whole 
thickness of the muscular wall. 

h. Supra-muscular. — All the muscular wall is attacked, but the 
peritonaeum, the bladder and the broad ligaments are not involved. 

2. Complete. — Peritonaeum involved. The uterine cavity is in 
direct communication with the peritonaeal cavity. 

3. Complicated. — Wound of a contiguous organ. Opening of the 
bladder or intestine. 

In view of the date of the puerperal state, into ; 

1. Ruptures of pregnancy. 

2. Ruptures of labor. 

3. Ruptures of post-partum. 



Diseases of the Genital System. 317 

Euptures of pregnancy and those of post-partum are relatively 
rare and result in most cases from traumatism. Their study pre- 
sents only a secondary interest and we shall confine this description 
to the rupture of labor. Frequency, 1 per 1000 accouchements. 

^Etiology and pathogeny . — Euptures at the moment of labor may 
be: 

1. Traumatic. — Abdominal traumatism, blow on the abdominal 
wall, penetrating wound. Intra-uterine traumatism, version, for- 
ceps, embryotomy, etc. 

2. Spontaneous. — Accouchement, with regard to the uterus alone, 
is the struggle between the uterine muscle and the obstacles which 
oppose the exit of the foetus, a veritable duel in which the victory 
generally remains with the uterus ; if not, the exhausted muscle, 
thinned by the struggle, is ruptured and the accident we study 
occurs. 

It is important to know : 

The causes of this exaggerated struggle. 
The circumstances which favor the rupture. 

Causes of the exaggerated struggle. — Periuterine, pelvic deformity, 
tumor of the contiguous tissues. Uterine, obliquity of the uterus, 
rigidity of the cervix. Intra-uterine, exaggerated size of the foetus, 
hydrocephalus, monstrosity, vicious presentation. 

Circumstances ichich favor rupture. — 

1. Uterine causes. 

Pathological uterus. — Thinning of a part of the wall, partial de- 
generation, malformation, cicatrix. 

Uterus rendered jMthological. — By ergot, by intra-uterine irritation 
(introduction of the hand or of an instrument). 

Normal uterus. — The progressive thinning of the inferior segment 
may be such (Fig. 371) that at a given moment it causes rupture. 

2. Periuterine causes. — Projection of the promontory. Abnormal 
projections of the pelvis (exostoses). Vulvo-vaginal atresia. 

3. Intra-uterine causes. — Projection of a hand or foot. Osseous 
splinters in consequence of embryotomy. 

Symptoms. — The woman suddenly feels a sharp pain in the ab- 
domen and sometimes a sensation of internal tearing. Following 
rupture there is a sensation of relative relief. The pains, however, 
quickly return, either as uterine contractions or under the form of 
peritonitis resulting from the rupture. 

In direct examination of the woman different cases may present : 

1. The foetus remains in the uterus. — Direct examination furnishes 
scanty information. At the level of the rupture an unequal region 
is felt, very painful to pressure. 

2. The foetus has passed completely or incompletely into the peri- 
tonceal cavity. — By palpation one finds above the tumor formed by 



318 Diseases of the Bony Pelvis. 

the uterus, the foetus making a more or less notable projection. 
Auscultation, silence. Digital examination, the uterine orifice 
does not present the foetus. 




Fig. 371., — Thinning of the inferior segment of the uterus 
previous to rupture (Bandl). 



The foetus has been expelled. — Accouchement is terminated except 
the delivery of the appendages. Intra-uterine touch alone can give 
in such cases valuable information. Eupture renders expulsion of 
the appendages impossible and as artificial delivery thus becomes 
necessary it is by introducing the hand into the uterus that the 
accident is perceived. 

The treatment is preventive and curative. 

Preventive, in all cases of serious dystocia, when the uterine con- 
tractions are energetic, by diminishing the pains by the use of 
chloroform and by aiding the uterus as much as possible. 

Curative. 

a. Before accouchement. — 1. The foetus is in the uterus. — Terminate 
accouchement by version, extraction, or forceps, provided the open- 
ing of the uterine orifice is sufficient , if not, act as in the following 
case. 

2. The foetus is partly or completely in the peritonceal cavity. — 
Laparotomy is the wisest course in all cases. In cases of too 
extensive laceration of the uterus Porro's operation may be per- 
formed. 

18. Uterine tumors. — Cancer has been studied in relation to the 
cervix. We have only to deal with the fibromata here. They are 
classified as follows : 



Diseases of the Bony Pelvis. 



319 



1. Interstitial (Fig. 372) : 

1. Of the body. 

2. Of the cervix. 




Fig. 372. 




Fig. 376. 



Fig. 377. 



2. Of the internal surface of the uterus {submucous) . 
1. Of the somatic cavity : 

A. Somatic habitat (Fig. 373). 

B. Cervical habitat (Fig. 374). 

C. Vaginal habitat (Fig. 375). 



320 



Diseases of the Genital System, 

2. Of the cervical cavity : 

A. Cervical habitat (Fig. 376). 

B. Vaginal habitat (Fig. 377). 




Fig. 378. 

3. Of the external surface of the uterus, 

1. Anterior wall (Fig. 378) : 

A. Body. 

1. Subperitonaeal fibromata : 

B. Cervix. 

1. Subperitonseal. 

2. Subvesical. 

3. Tntra-vaginal, 

2. Lateral wall (Fig. 379) : 

A. Body. 

1. Subperitonaeal. 

2. Intra-ligamentous. 

B. Cervix. 

1. Intra-ligamentous. 

2. Intra- vaginal. 

3. Posterior wall (Fig. 380) : 

A. Body. 

1. Subperitonaeal. 

B. Cervix. 

1. Subperitonaeal. 

2. Intra- vaginal. 

In view of dystosia, however, we may again divide the fibromata 
into : 

Lactero- superior fibromata. 
Fibromata praevia. 



Diseases of the Genital System. 



321 



The latero-superior cavity has a certain degree of interest in ob- 
stetrics, for the tumor may interfere with pregnancy by its size or 
by its situation near the placenta. The importance of fibroma 
praevia is, however, in a practical point of view, much more con- 
siderable. 




Fig. 379. 




Fig. 380. 

Every fibroma increases in size and is subject to a certain degree 
of softening under the influence of gestation, then it diminises after 
accouchement. Thus even a small tumor may become a serious 
obstacle to accouchement, by its growth. 

Fibroma prsevia (Fig. 381) predisposes to premature expulsion of 
the ovum, to vicious presentations, to premature rupture of the 
membranes, to procidence of the limbs or of the cord and to hsemor- 



322 



Diseases of the Genital System, 



rhages, but the most grave consequence is the difficulty or the im- 
possibility of accouchement. 




Fig. 381. — F, fibroma prgevia. 

The management of labor in these cases consists in : 

1. Waiting, when the life of the child, and that of the mother 
especially, are not in danger. Accouchement sometimes is termi- 
nated spontaneously when a most serious prognosis would have been, 
given. 

2. If spontaneous accouchement is impossible, recourse to the 
forceps, to version, or to extraction. It is generally better to deliver 
the child head first (forceps) than last (manual extraction). 

3. In grave cases where the forceps and manual extraction are 
insufficient there remain, as ultimate resources, the extirpation or 
the pushing up of the fibroma, embryotomy and Caesarian operation. 

Pushing up the fibroma should be attempted under chloroform, 
but this has chances of success only when the tumor is subperi- 
tonaeal, occupying Douglas' cul-de-sac. 

In cases of intra- vaginal fibromata, extirpation will be successful. 

Embryotomy will be preferable if the child is dead, or if, with a 
passage sufficiently large for convenient use of the instruments, 
pushing up the tumor or its ablation is impossible. 

Caesarian operation is the last resource that we are obliged to 
employ. 

19. Hernias of the bladder, of the intestine, ayid of the omentum. — 
Cystocele and rectocele do not demand any special treatment during 
labor, except that they should be kept reduced as much as possible. 



Diseases of the Genital System, 323 

In cases of inguinal, crural or umbilical hernia of the intestine, 
with or without omentum, reduction should be maintained by an 
appropriate bandage. The efforts of the patient should be abridged 
by the forceps or by extraction during the period of expulsion. 




Fig. 382. — Cyst of the broad ligament. T, cyst; U, cervix; 
Va, vagina (Budin). 

20. Tumors of the ovary and its vicinity. — Any abdominal tumor 
may interrupt the normal course of pregnancy and of accouche- 
ment. Among these, cysts of the ovary and of the broad ligament 
are especially to be mentioned on account of their relative im- 
portance. The cyst may fall into Douglas' cul-de-sac (Fig. 382) and 
obstruct accouchement. Puncture, then, permits us to remove the 
obstacle. During pregnancy, if the cyst is voliminous and there is 
fear of serious complications, it may be removed by ovariotomy. 



324 Diseases and Anoynalies of the Placenta. 



CHAPTER XX 



DISEASES AND ANOMALIES OF THE 
PLACENTA. 

1. Placentitis. — Inflammation of the placenta, if it exists, is not 
yet well understood. 

2. Atrophy and hypertrophy, which may affect the whole of the 
placenta or each element in particular, are without consequence 
unless accompanied by another pathological state. 

3. Apoplexy and hcemorrhage. — Placental haemorrhages or apo- 
plexies of maternal origin present under three forms : 1. Sanguine- 
ous infiltration, not well limited. 2. Focus with irregular walls. 
3. Clearly circumscribed focus. The blood thus suffused undergoes 
the usual evolution. The causes are cardiopathy, albuminuria, 
infectious disease, traumatism, fluxion coincident with menstrual 
period. Often there is no appreciable cause. It results in arrest of 
the development of the child, in its possible death, or in abortion. 
The treatment is nul, except that directed to the supposed cause. 
In women, who, during i)regnancy, have menstrually congestive 
symptoms relating to the uterus, a venesection of one hundred and 
fifty to two hundred grammes might be repeated at each menstrual 
period, if placental haemorrhage has caused interruption of previous 
pregnancies. 

4. (Edema exists, but it is not well understood. Its practical 
importance is nul. 

5. Fibro-fatty degeneration (sclerosis). — Under the influence of 
endometritis, of syphilis, or most often from an unknown cause, the 
chorial villi are invaded by fibro-fatty degeneration; the process is 
analogous to that which physiologically destroys the villi outside the 
placental zone. The placenta is thus partially or completely in- 
vaded from the periphery toward the center. The result is the 
enfeeblement or the death of the foetus, with consequent abortion. 
In an hystological and a pathogenetic point of view this degener- 
ation differs from placental apoplexy where the haemorrhage is the 
initial phenomenon, but the result is analogous. Often the two 
processes combine to cause placental destruction and death of the 
foetus. Treatment : Eemedy the endometritis and all pathological 
states of the genital organs. 

6. Calcareous degenerations. — A variety of petrification at dessemi- 
nated points, which often invades the placenta, especially at its 



Diseases and Anomalies of the Placenta. 325 

uterine surface. Cause, unknowTi. Influence on the development of 
the foetus, nul. 

7. Albuminuric alterations. — Whitish plaques, due to fibro-fatty 
degeneration. 

8. Syphilitic alterations. — Hyi^ertrophy of the villi. Fibrous de- 
generation. Caseous islets. Gummata. 

9. Cysts are frequent at the foetal surface. They have a volume 
from that of a nut to that of a mandarin. Some, of haematic origin, 
are comprised in the thickness of the chorion. Others, serous, formed 
by a substance analogous to Wharton's jelly, are situated between 
the chorion and the amnion. 

10. Solid tumors. — Fibromata. Angiomatous fibromata. Fibrous 
myxomata. Sarcomata. Not well known. Yery rare. 

11. Adhesions. — When expulsion takes place before term, in con- 
sequence of hsemorrhage, of degeneration, and most often without 
appreciable cause, there exists an abnormal adhesion between the 
uterus and the placenta, in such a way that separation is difficult, 
almost impossible. The adhesion is sometimes so great that after 
opening the uterus post-mortem it is impossible to detach the 
placenta without the aid of a cutting instrument. The manage- 
ment will be noted apropos of the complications of delivery. 

12. Hydatiform mole is the term used to designate a special 
degeneration of the placenta and its membranes. Its aspect recalls 
that of a hydatid cyst. The hydatiform mole is manifested by 
three principal symptoms : The abnormal development of the 
uterus, the uterine haemorrhages, and the escape of vesicles. A 
detachment of vesicles with expulsion, however, is rare, unfortu- 
nately for the diagnosis. 

The expelled mole iDresents sometimes under the form of a mass 
of vesicles from the size of a pinhead to that of a nut, not united 
in an envelope , sometimes, on the contrary, they are surrounded 
by the membranes of the ovum (Fig. 383). 

It is now admitted that the hydatiform mole is the result of de- 
generation of the ovuline appendages and m particular the chorial 
villi. However, accord is not yet complete on the nature of tliis 
alteration. Robin believes it to be a hydropsy of each villus. 
Yirchow attributes it to a myoma developing at the expense of the 
elements of villus, and causing cystic degeneration. 

Treatment. — 1. Before expulsion, simple expectation. If haemor- 
rhage becomes abundant, vaginal tamponnement becomes necessary, 
performed, we shall soon see, as for placenta prsevia. Provocation 
of labor is never indicated. 

2. During expulsion, cervix not open, same conduct as before. 
Cervix open, allow spontaneous expulsion, unless there is grave 



326 



Diseases and Anomalies of the Placenta. 



haemorrhage, in which case the hand will be introduced into the 
uterus to detach and to remove the whole mass. 

3. After expulsion, rigorous antisepsis. If the flow is fetid and 
contains debris, antiseptic intra-uterine injections are necessary, 
and at need curetting, completed or not by intra-uterine tamponne- 
ment. 




Fig. 383. — Hydatiform mole (Boivin). a, decidua; d, chorion and amnion; 
d, vesicls; c cf, vesicles of different size and form. 

13. Vicious insertion of the placenta. — Placenta prcevia. — Let us 
divide the uterus into three regions by two parallel planes, the in- 
ferior passing at eight centimetres from the internal orifice, the 
superior at eight centimetres from the superior pole of the uterus 
(Fig. 384). Every placenta, which, by any part of its surface, is 
inserted below the plane C D, is an inferior polar placenta or praevia. 
Likewise every placenta which, by any part of its extent, is inserted 
above the plane A B, is a superior polar placenta. Every placenta 
inserted between these two planes is equatorial or median. 

In one-third of all cases the placenta is inferior polar or praevia. 
In two-thirds of all cases the placenta is of the superior polar 
variety (normal or physiological insertion). It is quite exceptional 
for the placenta to be whole equatorial (Fig. 385). 

It will then be seen that placenta praevia is far from being rare. 



Diseases and Anomalies of the Placenta. 



327 



and that it becomes of importance by having its insertion on the 
uterine passage which the foetus must follow in its exit from the 
genital organs. 




Fig. 384. — A B, constitutes the superior polar circle; 
C D, the inferior polar circle. 




Fig, 385. — Different varieties of insertion of the placenta. 

There are four varieties of placenta praevia : 
1. Central placenta prcevia. — The center of the placenta corre- 
sponds to the internal orifice of the uterus. 



328 



Diseases and Anomalies of the Placenta. 



2. Partial placenta ijrcevia. — Some point of the placenta, interme- 
diate between its center and its border, corresponds to the internal 
orifice of the uterus. 

3. Marginal placenta prcevia. — The edge of the placenta lies over 
the internal orifice of the uterus. 

4. Lateral placenta prcevia. — The edge of the placenta is found at 
from one to eight centimetres from the internal orifice. All the in- 
ferior segment, which extends circularly to eight centimetres from 
the internal orifice, constitutes the zone of dangerous insertion. 

The frequency progressively increases from the first to the last 
variety. Central placenta prsevia is very rare. Lateral placenta 
praevia is the most common. 

Exceptionally, the placenta may be inserted in part in the cervical 
cavity (cervical pregnancy). The accidents and the management 
are the same as in central placenta praevia. 

I shall only mention cases in which there is a vicious insertion of 
an accessory cotyledon (Fig. 886). The management is the same 
as in ordinary placenta prsevia. 




Fig. 386. — Accessory cotyledon prsevia. 

In examining a partial or central placenta prsevia soon after its 
expulsion, three zones of different color are often found on its 
uterine surface : a central, corresponding to the internal os, pale 
and yellowish; an intermediate, reddish; a peripheral, clearer. 
These different zones are due to circulatory modifications of the 
placenta and to hgemorrhages during pregnancy. 

The foetus is usually less developed than in the normal state. 



Diseases and Anomalies of the Placenta. 329 

Symptoms. — a. Pregnancy. — Hasmorrhage, premature rupture of 
the membranes, vicious presentations of the foetus, premature ex- 
pulsion of the ovum, are four possible consequences of placenta 
prsevia. Any one of these symptoms allows us to think of a vicious 
insertion of the placenta. 

Every abundant haemorrhage occurring during the last three 
months of pregnancy, when there has been no flow of blood during 
the first six months, is the result of a placenta praevia. 

Direct examination furnishes certain confirmative signs. Amoiig 
these there are two of importance, the thickening of the inferior 
segment of the uterus, perceived by digital examination, and the 
vagueness which accompanies the perception of ballottement and 
which results from the presence of the placenta. The other signs that 
it is pretended can be gathered by palpation (placental doughyness), 
by auscultation (placental souffle), by touch (placental pulsation 
of Gendrin), have no real value. 

h. Accouchement. — To complete the history of placenta praevia 
during the period of opening of the cervix, it is sufficient to add the 
signs furnished at this moment by digital examination. The dila- 
tation of the external os permits us to arrive directly on the placenta, 
in case the insertion is partial or central. An unequal spongy body 
is then felt, quite different from the membranes. In cases of 
marginal or lateral insertion, the placenta can only be felt by in- 
troducing the finger quite far into the uterus, but in these cases, 
when the sac is intact, an experienced finger can devine from the 
thickness and the inequalities of the menbranes the vicinity of the 
placenta. 

During labor, if premature rupture of the membranes does not 
take place, various conditions may be produced. The bag of waters 
may be regularly formed and evolved as usual (marginal or lateral 
insertion). Again, this sac is constituted in part by the placenta 
and in part by the membranes (partial insertion), rupture occurs, 
by preference, at the union of the placenta and the membranes, the 
placental flap being thrown aside by the foetal part in its descent. 
Or, finally, the placenta alone takes the place of the bag of waters 
(central insertion) and in such cases two circumstances may exist, 
either the foetus passes through the placenta, rupturing it, or it 
pushes this organ before it. It is useless to say that in the latter 
case the death of the foetus is certain. 

Prognosis. — The prognosis is grave for the child, for about 50 per 
cent of foeti succumb. With regard to the mother, antisepsis has 
caused a great diminution in the danger of vicious insertion, since 
in place of 24 per 100 the mortality has fallen to about 5 per 100. 

The gravity of the prognosis depends : 

Upon the moment at which the first haemorrhage appears —the 
earlier it takes place during pregnancy the darker is the prognosis, 



330 Diseases and Anomalies of the Placenta. 

for, in general, the flow is as much more precocious as the placenta 
is near the internal os ; 

Upon the variety of the insertion — the more the insertion ap- 
proaches the central variety the greater is its gravity ; 

Upon the resistance of the uterine orifice to dilation; 

Upon the intensity of the uterine contractions ; 

Upon the foetal presentation ; 

Upon the death of the cliild — the death of the foetus occurring 
during pregnancy, retards the activity of the utero-placental circu- 
lation and consequently ameliorates the prognosis of the haemor- 
rhage; 

Upon the treatment — the treatment followed plays a considerable 
role with regard to the prognosis. 

Treatment. — The methods of treatment directed against placenta 
praevia are numerous. They are abridged in the following table : 

A. Mother. 

I. In the struggle against the haemorrhage. 

1. Method of Dubois, ergot (1836). 

2. Method of Seyfert, vaginal injection (1852). 

3. Method of Leroux, tampon (1776). 

II. To open the cer\ix. 

4. Method of Guillemeau, forced accouchement (1571). 

5. Method of Barnes, rubber bags (1862). 

6. Method of Greenhalgh, induced accouchement (1865) . 

B. Ovum. 

I. Detachment of the placenta. 

7. Method of Simpson, total separation (1844). 

8. Method of Barnes, partial detachment (1862). 

9. Method of Bunsen, partial separation (1839). 

I. Drainage of the liquor amnii. 

10. Method of Puzos, rupture of the membranes (1759). 

11. Method of Cohen, rupture after placental detachment 

(1855). 

12. Method of Deventer, perforation of placenta (1734). 

III. Action on the foetus. 

13. Method of Kristeller, foetal expression (1865). 

14. Method of 

a. Wigand, external cephalic version (1812). 
h. Braxton Hicks, mixed podalic version (1864) . 

15. Method of (no special name), extraction by the for- 

ceps, by the hand (with or without version), or by 
embryotomy. 



Diseases and Anomalies of the Placenta. 



331 



It is impossible to treat in detail the description of these different 
methods and I shall confine the discussion to those that are in- 
dispensable in the treatment of placenta praevia during pregnancy, 




Fig. 387. — Gariel's pessary. 

accouchement, and delivery of the appendages. In all the thera- 
peutic measures it is the genital haemorrhage that is always in -sdcw, 
which constitutes the principal accident of the vicious insertion and 
against which the treatment should be directed. 




Fig. 388. — Tampon applied. A, deep rolls furnished with a thread ; 
B, superficial free rolls; C, layer of charpie ; D, T bandage. 

a. Pregnancy. — If the haemorrhage be slight simple expectation is 
necessary ; if, on the contrary, it be serious, recourse should be had 
first to vaginal tamponnement (Fig. 388), then, if this fail, to 



332 



Diseases and Anomalies of the Placenta. 



rupture of the membranes, preceded or followed, at need, by the 
application of Barnes' rubber dilator. The most simple means for 
vaginal tamponnement is Gariel's pessary (Fig. 387). But if the 
inflated rubber-bag is not sufficient, the more comphcated method 
of packing the vagina with rolls of absorbent cotton or charpie be- 
comes at once necessary. In the place of these I prefer strips of 
iodoform gauze. After application the tampon is fixed in place 
and supported by a T bandage (Fig. 389). 




Fig. 389. — T bandage holding the tampon (Bailly). c c, the two ends of the 
bandage are turned back leaving the abdomen completely free. 

If, in spite of the application of the tampon, the haemorrhage 
continues and consequently becomes menacing, more active 
measures are necessary, that is, the interruption of pregnancy by 
a premature accouchement. Two cases may present : 

(1). Where the membranes are easily accessible, — Multiparas, with 
gaping cer\dx and with a marginal or a partial insertion of the 
placenta. The membranes can then be largely ruptured with the 
nail or a blunt instrument, so as to free the placental border to a 
sufficiently large extent, after being previously assured that there 
exists a presentation of the vertex or breech. Any other pre- 
sentation than that of the vertex should first be converted into a 
breech by external or mixed manoeuvres, and one of the lower 
limbs drawn into the uterine opening as soon as possible, by the 
method of Braxton Hicks soon to be described. In cases of vertex 
presentation, after the rupture of the membranes, a Barnes' dilator 
(Fig. 390) will be applied in the cervix, so as to induce and to 
hasten labor. 

(2). The membranes are not easily accessible. — Primiparae, with a 
closed cervix, and with partial or central insertion of the placenta. 



Diseases and Anomalies of the Placenta, 



333 



In such cases, the dilatation of the cervix is begun with a Barnes* 
rubber-bag, preceded at need by the introduction of the finger to 
facilitate the passage of the dilator. At the end of some time the 
rubber sac is withdrawn, and, if the membranes are accessible, 
they are ruptured, as in the preceding case. If the opening of the 
cervix is still insufficient, a dilator of larger size should be applied 
and after another interval the membranes will again be sought. In 
cases of inaccessible membranes, Cohen's method consists in de- 
taching the placenta with the fingers in a given direction until the 
membranes are found and perforated, liberating a placental flap 
which can be applied against the uterine wall ; the difficulty in this 
theory consists in devining the side of the placenta at which will be 
found the shortest way to the appendages. 




Fig. 390. — Barnes' dilators. 

h. Labor. — Intervention should have place only when the haemor- 
rhage is serious. Let us distinguish two cases, presentation of the 
vertex and presentation other than the vertex. 

1. The vertex presents. — The best and most simple method is that 
of Puzos, that is, artificial rupture of the membranes followed by 
the application of Barnes' dilator when the dilatation is less than 
two finger's breadth. If the membranes are inaccessible the pro- 
cedure is commenced by the application of Barnes' dilator, as has 
been indicated in the treatment during pregnancy. 

2. Presentation other than vertex. — In such cases Braxton HicKs' 
method should be resorted to; if the breech presents it is sufficient 
to draw a foot down into the pelvis ; if not, after previous rupture 
of the membranes, podalic version is performed by mixed ma- 
noeuvres, terminating in drawing a foot down. When dilatation is 
insufficient, or the membranes inaccessible, a Barnes' dilator is 
applied, as before, to facilitate the intervention by a previous dila- 
tation. 

If Puzos' method or that of Braxton Hicks does not succeed in 



334 Diseases and Anomalies qf the Placenta. 

arresting the haemorihage, which is quite exceptional, and if the 
condition of the woman appears serious, one should have recourse 
to forced accouchement (method of Guillemeau). This method 
consists in applying the forceps on the vertex as soon as the dila- 
tation of the cervix will permit the introduction of the blades, or in 
making extraction as soon as a foot can be brought into the vagina. 
But forced accouchement should only rarely be practiced on 
account of the uterine lacerations to which it exposes. 

c. Delivery of the appendages. — If a haemorrhage occurs at tliis 
moment, the usual conduct in such cases is followed. 

d. Stimulant and reparative treatment. — When the woman becomes 
anaemic in consequence of an abundant haemorrhage, susceptible 
even after delivery of exposure to fatal syncope, one or more of 
three stimulants should be used — alcohol internally, ether subcu- 
taneously, heat to the periphery and internally at need (hot drinks). 

Finally, in grave cases transfusion of blood should be used, but 
in place of the ordinary transfusion, which requires a special ap- 
paratus, the auto-infusion of Dr. Prouff should be used. This con- 
sists in compressing the lower limbs, and the upper if necessary, 
by a rubber band, pushing the blood from the extremities toward 
the trunk. The compression of each lower limb causes the reflex 
of 120 to 150 grammes of blood, equivalent to a transfusion of the 
same amount of blood (about three hundred grammes for both lower 
limbs). 



Diseases of the Ovuline EnvelojKs, 335 



CHAPTER XXI. 



DISEASES OF THE OVULINE ENVELOPES. 

1. Amnion. — Inflammation of the amnion is generally admitted. 
The result of this may be the augmentation of the liquor amnii and 
the formation of amniotic bands connecting the surface of the 
amnion and the foetus. 

2. Chorion. — Besides the hydatiform mole, already noted, there 
is observed either an hypertrophy of the villi or an hypertrophy as 
a whole with numerous nodules (chronic inflammation). 

3. Deciduas. — Inflammation of the connective tissue framework 
produces diffuse endometritis ; that of the cells of the decidua, poly- 
poid endometritis, that of the glands, cystic endometritis. These 
various varieties of endometrites which especially affect the uterine 
and the utero-placental deciduas are a cause of abortion. Atrophy 
of the decidua, which has been considered as a possible cause of 
abortion, is scarcely known. 

Hydrorrhoea occurs after the second month of pregnancy, most 
often during the last three months, as a sudden loss of a liquid 
analogous to that contained by the amnion. Sometimes its flow is 
remittent, sometimes intermittent, and after each abundant flow of 
liquid the patient notes a diminution in the size of the abdomen. 
This aqueous loss comes from the ovum and it terminates in one of 
two ways : either the flow ceases and pregnancy continues its course 
to normal term, or there is premature expulsion of the ovum. In a 
pathological point of view, two varieties of hydrorrhoea are accepted 
to-day. One, without rupture, of the ovum, is a decidual hydrorrhoea, 
caused by a more or less localized inflammation of the decidua and 
its glands. The other is an amniotic hydrorrhoea constituted by a 
premature rupture of the membranes. 

The treatment of hydrorrhoea consists, in part, of repose in bed 
or in a recumbent position, in part of quieting the uterus by vibur- 
num prunifolium or opiates, as if in menacing abortion. This pro- 
longation is only in the interest of the foetus and will not be carried 
out if it is dead. 

4. Cord. — The length of the cord, which measures on the average 
a half metre, between and 3 metres. Excess of length exposes to 
procidence and to circles around the child ; brevity, to more serious 
consequences. During pregnancy shortness of the cord may be the 



336 Diseases of the Ovidinc Envelopes. 

cause of a sharp pain in a localized region of the uterus, of a vicious 
presentation, and sometimes of detachment of the placenta, a source 
of hgemorrhage. During labor the same disadvantages may be 
observed and also a certain slowness in the dilatation of the cervix, 
due, without doubt, to the obstruction to the free descent of the 
foetus. It is then sometimes necessary to use manual extraction 
or the forceps, with the possible consequence of death of the fcetus 
and rupture of the cord. 




Fig. 391. — Knot of Baudeloque (Charpentier). 

Knots in the cord, which form under the influence of the evolutions 
of the child, may present varied appearances (Fig. 391). Their 
practical importance is nul, for, contrary to what might be sup- 
posed, they are incapable of completely interrupting the funicular 
circulation. 

Exaggerated torsion of the cord on itself is capable of causing the 
death of the foetus, but this cause should be considered as exceptional. 

Obstruction of the funicular vessels may also be caused by in- 
trinsic causes, such as phlebitis of the umbilical vein, malformation 
of the cord, shortness, tumors, or simple stenosis of the vessels. 

5. Liquor amnii. — Hydramnios. — Whenever the quantity of the 
liquor amnii exceeds one thousand grammes we have hydropsy of 
the amnion. It occurs in the proportion of one to one hundred 
pregnancies. In a general way, we may say that hydramnios has a 
pathogeny analogous to all the hydropsies, its source is in a circu- 
latory obstruction. With regard to the foetus, we recognize three - 
causes : 

1. Syphilis, which acts through the hepatic or the placental lesions 
which it causes, both being a source of circulatory disturbances. 

2. Malformations, indicating a vice in the constitution of the 
foetus, in which the circulation becomes insufficient. 

3. Twin pregnancy, where the circulation of one foetus is ob- 
structed by the more vigorous. Sometimes the two circulations 
are mutually interrupted, producing hydramnios of both amniotic 
membranes. 

With regard to the mother, the causes are the same as those which 



Diseases of the Ovuline Envelopes. 337 

produce dropoy, oedema, and anasarca. Thus hydramnios is often 
seen to coincide with these different diseases of the pregnant woman. 

Symptoms. — Hydramnios is manifested under two forms, acute 
and chronic. 

The chronic form oegins insiduously ; the exaggeration in the 
quantity of liquid becomes notable after the fifth or sixth month. 
The abdomen is abnormally developed. There are abdominal and 
lumbar pains, respiratory obstruction, and very clear sensation of 
the active movements of the foetus. 

The acute form produces rapid development of the abdomen, 
giving rise to the same physical signs as the preceding. But the 
functional troubles here take a pronounced gravity ; the pains are 
acute, the respiration is difficult, the face is bluish, and there is 
frequent and obstinate vomiting. The termination takes place by 
death (when not interrupted by active intervention), by expulsion of 
the ovum, or by transformation into the chronic form, with attenu- 
ation of the symptoms. 

The chronic form is relatively benign, but it exposes to premature 
accouchement, to vicious presentations, to procidence of the cord, 
and to slowness of labor. 

The acute form is grave for it most often terminates in the death 
of the woman or m the premature expulsion of the ovum. In hy- 
dramnios ot both varieties, eclampsia and grave haemorrhages are 
to be feared. 

The prognosis, with regard to the child, depends as much on the 
cause of the hydramnios (syphilis, malformations, etc.), as on the 
hydropsy itself. 

Treatment. — Chronic form. — Simple expectation during preg- 
nancy. At the moment of labor the membranes should be ruptured 
early in cases where the three following conditions are united : slow 
contractions, vertex presentation with marked engagement, cervix 
effaced and offering a dilatation of, at least, two fingers' breadth. 

Acute form. — If the rapidity of the accidents menace the patient's 
existence we are authorized to have recourse to a capillary puncture 
of the ovum (through the abdomen or vagina) or to an induced ac- 
couchement. 

Deficiency of the liquor amnii. — Hypoamnios. — A want of amniotic 
liquid predisposes to deformations of the foetus, and during labor to 
a slow and difficult progression of the f(Btus, on account of the 
drvness. 



338 Diseases and Death of the Foetus, 



CHAPTER XXII. 



DISEASES AND DEATH OF THE FOETUS. 
FCETAL DYSTOCIA. 

1. Excess of the volume of the foetus. — The excess of the volume of 
the foetus may be simple or pathological. It is simple when there 
is an exaggeration of the fcetal development, without trace of disease. 
If pathological, it comprehends all the causes capable of producing 
hypertrophy of a foetal region; such are, hydrocephalus, hydro- 
thorax, ascites, tumors, monstrosities, etc. Each of these causes 
will be studied separately. First we shall take into question simple 
excess of volume. 

Simple excess of volume may be generalized or localized. 

It is generalized when a well-proportioned child presents a de- 
velopment superior to that ordinarily observed. In the place of 
three kilogrammes it weighs four, five, or even more. The obstacle 
to accouchement lecomes the same as that created by a deformed 
pelvis with a foetus of normal size and, at the moment of accouche- 
ment, the management will be the same. Some women present an 
excess of foetal volume at several consecutive pregnancies and the 
question of premature accouchement will present itself in such cases, 
for this will sometimes be the only way of having a living child. 
The epoch at which this should take place will be fixed by the study 
(by palpation) of the relation existing between the size of the head 
and the pelvic canal. 

The hypertrophy is localized when there is relative excess in the 
volume of the head, of the shoulders, or of the breech. The excess 
of the volume of the shoulders is the only one proven. It may 
become an obstacle to accouchement whether the head presents 
first or last. In cases of presentation of the vertex, when the head 
no longer advances, before or after having opened the vulva, the 
shoulders being arrested at the superior or at the median strait, the 
forceps will bring the head outside the vulva. Then if simple 
tractions are not sufficient to cause descent of the shoulders, the 
two arms should be successively sought and brought down, the 
anterior first. The shoulders then engage without difficulty and 
the child may be extracted. In cases of the head coming last, the 
same manoeuvres should be used. 

2. Hydropsias. — Hydrocephalus; Hydrothorar ,- Ascites. 
Hydrocephalus is constituted by an abnormal accumulation of 

serous liquid in the cranial cavity. Hydrocephalus may exist 



Diseases and Death of the Foetus, 839 

alone or it may be complicated by hydrorhachis, spina bifida or 
some other foetal malformation. The size of the head is variable. The 
increase is made at the expense of the cranial vault (Fig. 392). Its 
frequency is about 1-2000. Its causes are not well known. Syphilis, 
cretinism, and consanguinity have been noted. 




Fig. 392.— Hydrocephalic head, retained at the superior strait (Playfair). 

During pregnancy hydrocephalus may be suspected from the 
size of the head, revealed by palpation. In general, it is at the 
moment of labor, when the dilated cervix permits access, that the 
diagnosis becomes possible. It will then be made when the head 
comes first by the recognition of large fontanelles, and of the un- 
usual interval between the sutures. When the head comes last 
manual exploration leads as before to a diagnosis from the con- 
dition of the sutures. 

At the moment of labor the management will vary according as 
there is a presentation of the cephalic or of the cormic ovoid. 

Presentation of the cephalic ovoid. — Expectation until complete dila- 
tation is the rule. If the head does not engage an application of 
the forceps should be attempted. If the forceps fail, recourse should 
be had to capillary puncture of the cranium through a suture or a 
fontanelle, without removing the forceps, and the tractions should 
again be resumed after evacuation of the liquid. Embryotomy con- 
stitutes the ultimate resource. 

Presentation of the cormic ovoid. — The difficulties only exist for the 
extraction of the head. This will be successively attempted as 
above by the aid of manual tractions after the evacuation of the 
liquid or after embryotomy. The evacuation of the fluid may be 
obtained by capillary puncture of the cranium, or by Van HueveFs 



340 



Diseases and Death of the Foetus, 



method (Fig. 393) which consists in cutting the vertebral column 
transversely and passing a sound by this opening through the 
spinal canal into the cranium. 
Hydrothorax only exists as a complication of ascites. 




Fig. 393. — Evacuation of the hydrocephalic liquid by the spinal 
canal (Van Huevel). 

Congenital ascites is very rare and most often coincides with a 
certain degree of peritonitis. The diagnosis can only be made at 
the moment of labor, when there exists difficulty in the extraction 
of the trunk. Treatment : evacuation by puncture. 

3. Diseases of the urinary apparatus. — Eetention of urine, which 
accompanies imperforation of the urethra, may produce a con- 
siderable distention of the abdomen (Fig. 394). It requires the 
same treatment as ascites. 

4. Diseases of the bones and of the articidations. — Intra-uterine 
fracture of the foetus may be traumatic, and due to a blow affecting 
the abdominal region of the mother, or spontaneous, and produced 
by an osseous friability caused by rachitis. 



Diseases and Death of the Fdetus. 341 

Congenital luxations may attack nearly all the articulations but 
those of the hip joint are most frequent. The spontaneous luxations 
should be distinguished from those produced during delivery under 
the influence of an obstetrical intervention and which are relatively 
rare. 




Fig. 394. — Retention of urine (Portal). 

Intra-uterine rachitis causes a deformation of the skeleton, es- 
pecially resulting in shortness of the upper and lower limbs. 

Foetal ankylosis is characterized by a stijBPness of the majority of 
the articulations. The foetus remains as if congealed in the 
attitude that it has in the uterus. From this proceeds possible 
difficulties for extraction. The nature of these ankyloses is still 
unknown. 

5. Various tumors. — Spina bifida. Sacral hygroma. Fibromata. 
Sarcomata. Generalized oedema and emphysema. 

6. Congenital amputation. — The child is born with a lower or an 
upper member missing. The divided member terminates in a 
Tegular stump. 

There are two theories as to causation : One, that the circular 
strangulation is produced by the umbilical cord or by a pathological 
amniotic band. The other, that the production of a cutaneous 
cicatrix in consequence of a local inflammation results in a pro- 
gressive stricture terminating in gangrene of the subjacent parts of 
the limb. 

Death of the fcBtus. 

The death of the foetus may be real or apparent. The death is 
real when the foetus cannot be recalled to life by any known 
means, it is apparent in the contrary case. Death of the foetus 



342 Diseases and Death of the Foetus. 

taking place during pregnancy will be necessarily real on account 
of the time that separates it from birth. But death occurring 
during labor will sometimes be real and sometimes apparent 
according to the duration before expulsion and also to the cause 
producing it. It will be seen, then, leaving aside the setiological 
element, that during accouchement the difference between real and 
apparent death is constituted by a question of time ; both are de- 
grees of the same accident, apparent death ends in real death if it 
is prolonged. 

These intimate connections make it better to unite in the same 
chapter the study of these two varieties of death; after having 
examined their aetiology, common to both at least during labor, we 
will discuss separately the pathological anatomy, the symptoms, 
the diagnosis, the prognosis, and the treatment. 

Etiology. 
I. During pregnancy, — Real death, 

a. Traumatic causes : 

1. Maternal traumatism, genital or perigenital. 

2. Ovuline traumatism, attacking the ovum or the 

foetus directly. 

h. Non-traumatic causes. 
Father: 

1. General state : 

1. Advanced age ; debilitation from excess. 

2. Poisoning: Lead, tobacco, alcohol. 

3. Syphilis, scrofulo-tuberculosis, diabetes, albu- 

minuria. 

2. Localized states : 

1. Any defect of the genitals. 

Mother: 

1. General state : 

1. The same as for the father. 

2. Any grave disease occurring during pregnancy. 

2. Localized state : 

1. Periuterine or uterine affection (including 

tumors). 

2. Utero-placental haemorrhage. 

Ovum: 

1. Appendages : 

1. Placenta: Apoplexy, degeneration, hydatiform 

mole. 

2. Cord : Compression, loops, torsion, knots. 



Diseases and Death of the Foetus. 343 

2. Foetus: 

1. Various diseases of the foetus. 

2. Vices of conformation. 
8. Habitual death. 

8. Extra-uterine pregnancy. 

II. During labor. — Real or apparent death. 

a, .Traumatic causes. 

i. Maternal traumatism, genital or perigenital, 
attacking the uterus through the abdominal 
wall or by the vagina. 

2. Ovuline traumatism (version, forceps, embry- 
otomy). 

b. Non-traumatic causes. 

Mother: 

1. General conditions : 

1. Eclampsia. 

2. Asphyxia or grave asystole. 

3. Death of the mother. 

4. Any grave disease capable of determining pre- 

mature accouchement may, at the same time, 
cause the death of the foetus. 

2. Localized conditions : 

1. Uterine or periuterine affections capable of 

seriously obstructing accouchement. Uterine 
tetanus. 

2. Utero-placental haemorrhages. 

Ovum: 

1. Placenta : Extensive detachment. 

2. Cord : Compression, loops, torsion, knots. 
8. Foetus. 

Too long duration of labor. Intra-cranial effu- 
sion. Presentation of face : compression of 
the vessels of the neck. Presentation of the 
breech: slo\vness of extraction of the head. 
In general, any difficulty of accouchement 
proceeding from the foetus 

I. Real death. — Pathological anatomy. — The foetus having suc- 
cumbed, if it is still in the embryotic state, may undergo a complete 
dissolution and disappear; if not, it becomes macerated. Mace- 
ration may be clearly distinguished from putrefaction, for it occurs 
without odor, without the production of gas, and does not expose 
the woman to any septicsemic accident. 

In maceration there is a progressive softening of all the organs. 
The epidermis, upraised by phlyctenulae, is detached to a greater 



344 Diseases and Death of the Foetus, 

or less extent. The liquor amnii becomes, successively, reddish, 
greenish, chocolate-colored, and grumous. The placenta appears 
as if washed out. 

Maceration is produced when the membranes are intact and the 
foetus isolated in the amniotic liquid. In cases of perforation of the 
membranes and access of air to tne foetus, putrefaction takes place. 

Mummification is a variety of maceration in which the foetus 
becomes desiccated. 

Lithopsedion is only produced in cases of extra-uterine pregnancy. 

Symptoms. — a. During 2)'^egnancy. — 

1. Interrogation. — Establishment of the lacteal secretion, analo- 
gous to that occurring after delivery. Cessation of the sympathetic 
phenomena. Diminution of albuminuria in cases where it exists. 
Diminution of varices. Cessation of the foetal movements, when 
they have already been perceived. Special sensation of weight, of 
an inert mass in the abdomen. 

2. Inspection. — No special sign. 

3. Palpation. — The sensations furnished by the foetus become 
more and more vague. Uterus stationary or diminishing in volume. 
Sometimes a sensation of crepitation caused by the over-riding of 
the bones of the head. 

4. Auscultation. — Foetal silence. Eustling isochronous with the 
pulse of the mother, indicated by Stoltz (?). 

5. Digital examination. — Furnishes only little information during 
pregnancy, sometimes permitting, however, the perception of the 
mobility and even the crepitation of the bones of the cranium. 

h. During labor. — Same results as during pregnancy, afforded by 
interrogation, palpation and auscultation. 

Inspection.- — Flow of liquor amnii, greenish, reddish or chocolate 
color. 



Digital examination. — 

\g and mobility of the bones. 

Epidermic exfoliation 



Vertex presentation — over-riding and mobility of the bones. 
Face presentation — mouth, no suction. 
Breech presentation — anal sphincter, no contraction. 
Thorax presentation — hand, no movement. 

The treatment will be addressed to the cause that is supposed to 
have produced the death of the foetus. Syphilis occupies the first 
rank here. Under aetiology I have mentioned habitual death of the 
foetus. This term is used to designate the death of the foetus occur- 
ring during a series of pregnancies at about the same epoch. The 
treatment in such cases consists in inducing accouchement some 
days before the usual period at which the foetus succumbs, to allow 
delivery of a living and viable child. That is to say, that inter- 
vention will be useless in eases where the habitual death occurs 
before the beginning of the seventh month. 



Diseases and Death of the Foetus. 345 

II. Apparent death. — The child born m a state of apparent death 
presents, according to the cases, two absolutely distinct appear- 
ances : 

It sometimes appears violaceous, all the peripheral vessels are 
engorged with blood, the pulsations of the heart are clearly per- 
ceptible ; the prognosis is relatively benign. 

It sometimes appears tchite, the skin seems deprived of blood, the 
pulsations of the heart are feeble, sometimes nul, or difficult to per- 
ceive ; the prognosis is relatively grave. 

In the first case there is respiratory syncope, asphyxia, properly 
so-called, due to arrest of the placental function, pulmonary respi- 
ration being not yet established. In the second case there is cardi>ic 
syncope, comj)lete or incomplete. The first form quickly ends in 
the second, the respiratory syncope conducing to the cardiac. If 
the cardiac syncope lasts a certain length of time (difficult to state 
precisely) apparent death gives place to real death. 

At birth, the absence of respiratory movements and of cries in- 
dicates plainly the grave state in which the child is found. To know 
if the death is real or apparent, the condition of the heart must be 
observed by grasping the umbilical portion of the cord or by applying 
the hand or the ear on the prsecordial region. Whenever the pul- 
sations are perceptible, death is only apparent. If the pulsations 
are nul insufflation will be attempted for about half an hour, and if 
after this time no pulsation can be perceived it may be concluded 
that death is real. 

Treatment. — The mouth and the pharynx should be cleansed of 
mucus by the finger covered with a soft cloth. The treatment con- 
sists in attempting to arouse cardiac action by insufflation, or by 
other means intended to re-establish the respiratory function. 

a. Methods other than insufflation: 

1. Bleeding of the cord. — Generally abandoned at present. 

2. Electricity. — Interupted currents, one pole on the vertebral 
column at the upper part of the dorsal region, the other moved over 
the pectoral region from side to side. 

3. Cutaneous excitation. — Simple frictions, alcohol along the 
vertebral column, flagellation, hot baths or alternately hot and cold 
plunge baths. 

h. Insufflation. 

Indirect insufflation. — 1. Marshall Hall. — The child is laid on the 
abdomen, then turned on the side and finally given a sudden move- 
ment replacing it in its first position. This is performed fifteen to 
twenty times a minute. 

2. Schultze. — The child is grasped by the shoulders, the abdomen 
turned forward, and by a movement through the arc of a circle it is 
carried upward, as if turning a summersault, then it is lowered 



346 



Diseases and Death of the Foetus. 



by a movement in the opposite direction. The elevation produces 
expiration, the descent inspiration. 

3. Sylvester.— The child is grasped by the breech and the neck 
and given a sudden movement, parallel to itself, of elevation (ex- 
piration) and of descent (inspiration). 

4. Howard. — Respiratory movements are given to the thorax, 
either directly by the hands or by raising and lowering the arms. 

5. Woilez. — Spirophore, a case enclosing the child to which respi- 
ratory movements can be given. 

All these methods of indirect insufflation afford actual service 
but are inferior to direct insufflation. 




^ 



Fig. 395. — Chaussier-Depaurs tube. 

Direct insufflation may be made mouth to mouth or by the use 
of the laryngeal tube. As the former method is often repugnant 
insufflation by means of the laryngeal tube is generally preferred. 
For this puri)ose Chaussier has invented a metallic tube that has 
been slightly modified by Depaul (Fig. 395). This tube is intro- 
duced into the larynx under the guidance of the finger (Fig. 396) 
and serves to inflate the lungs. 




Fig. 396. — Application of the insufflator (Ribemont's tube). 

How long should insufflation he continued? If the child returns to 
life little by little, as indicated by the increasing frequence of the 



Diseases and Death of the Foetus. 347 

spontaneous inspirations, the insufflations should be continued until 
respiration occurs ten to fifteen times a minute. 

But if the return to life is slow to appear, at the end of what 
length of time should we despair? The management may be 
summed up in the following propositions : 

1. If after a half hour of insufflation, the pulsations of the heart 
are nul, it is useless to continue ; the death is real. 

2. When the cardiac pulsations exist, if after an hour of insuf- 
flation no spontaneous movement of respiration is produced, the 
efforts may be discontinued, for this absence of respiratory move- 
ments indicates that the child has undergone some lesion incom- 
patible with the re-establishment of life. 

3. If after two hours of insufflation, and when cardiac pulsations 
and some spontaneous respirations exist, the movements diminish- 
ing and tending to disappear as soon as insufflation is interrupted, 
it will be useless to continue longer, the conditions necessary to 
life being wanting, as in the preceding case 

Teratology. — I shall only give here a very short glance at this 
question, by conforming to the classification of Saint-Hilaire. The 
teratology comprises the hemiterias, the heterotaxias, the herma- 
phrodisms and the monstrosities. 

1. Hemiterias. — Among the principal hemiterias are : 

Encephalocele, meningocele, spina bifida. Harelip, 

Imp erf oration of the oesophagus, of the anus, of the urethra. 

Diaphragmatic and umbilical hernias. Cardiac ectopia. 

Non-descent of the testicles. 

Hypospadias. Epispadias. 

Duplicity of the uterus and of the vagina. 

Polymazia. Polydactylism. 

Clubfoot. 

2. Heterotaxias. — Total or partial splanchnic version. The organs 
occupy a position other than normal. 

3. Hermaphrodisms. — Hermaphrodism is designated the reuion, 
in the same individual, of the male and female genital organs, one 
or the other being anatomically or physiologically incomplete. 

4. Monstrosities. 

a. Simple monsters, in which a limb or the head is wanting. 
h. Composite monsters formed by the fusion of two or three foeti 
simultaneously developed in the uterine cavity. 



348 



Multiple Pregnancy. 



CHAPTER XXIII. 



MULTIPLE PREGNANCY. 

Two to five foeti may be simultaneously contained in the uterine 
cavity. Multiple pregnancies of more than five children are not 
clearly proven. In the study of multiple pregnancy we shall adopt 
the following plan : 

I. Twins. 

A. Pregnancy. 

B. Accouchement. 

a. Eutocia. 
h. Dystocia. 

II. Three to Jive children at a birth. 




Fig. 397. — Foeti in 9 9. 

I. T'wins. — A. Pregnancy. — Physiology. 

a. Fecundation. — Sometimes the two children are conceived 
simultaneously, sometimes there is a variable interval between 



Multiple Pregnancy. 



349 



them. In the first case there is simultaneous fecundation ; in the 
second, superfecundation or superimpregnation. 

Superfecundation is subdivided into superovulation, superembry- 
onnement, superfoetation, 

Superovulation. — The two successive fecundations very near, from 
some hours to eight days. 

Superemhryonnement. — The two successive fecundations are separ- 
ated by an interval of eight days to three months. 

Superfoetation. — The two successive fecundations occur at an 
interval greater than three months. 




Fig. 398. — Foeti in 6 6. 

The first two varieties are beyond doubt, but superfoetation is not 
generally admitted, for at this moment the two deciduas being 
united, communication between the vagina and the tubes is inter- 
rupted. 

h. Disposition of the foeti. — The various dispositions may be ar- 
ranged in three classes, lateral, where the twins are side by side; 
antero-posterior, one before the other, and lastly, superposed, one 
above the other. The first disposition is much the most frequent, 
the last two being exceptional. 



350 Multiple Pregnancy, 

I. Lateral. 

1. Foeti in 9 9,* the two heads are below, one generally engaged, 
the other in the iliac fossa (Fig. 397). 

2. Foeti in 6 6, the two breeches are below; one in relation with 
the superior strait, the other in the iliac fossa (Fig. 398). 

3. Foeti in 6 9 or in 9 6 (Fig. 399). 




Fig. 399, — Foeti in 6 9 (Budin). 

II. Antero -posterior. 

4. The two foeti are placed one before the other (Fig. 400). 

III. Superposed. 

5. Foeti in T. The upper foetus lies transversely at the fundus of 
the uterus, the lower is vertical, presenting by the breech or by the 
head (Fig. 401). 

6. Foeti in j, inverted. The upper foetus is vertical, the head 
below or above, the inferior lies transversely in the pelvis (Fig. 402). 

7. Foeti in hammock. The two foeti are transverse one above the 
other (Fig. 403). 

c. Disposition of the appendages. 

1. Separation. — The two ovuline appendages are completely dis- 

* I compare the foetus to the figure 6, the rounded part representing the breech and 
the terminal part the head. 



Multiple Pregnancy. 



351 




Fig. 400. — Foeti antero-posterior.(Budin). 




Fig. 401.— Foeti in T (Budin). 



352 



Multiple Pregnancy. 




Fig. 402. — Foeti in j^ (Budin). 




Fig. 403. — Foeti in hamnock (Budin). 



Multiple Pregnancy. 



353 



tinct. The septum which separates the two foeti is composed of the 
two amnions and of the two chorions, between which some elements 
of the decidua may be interposed (Fig. 404). 




Ol ,cnla 



Cftwiot* 



Fig. 404. — Distinct sacs: chorio-amniotic septum. 

2. Attachment. — The two placentae are united in a single masj in 
which the circulation of the two foeti is sometimes distinct, some- 
times common. There is only a common chorion, but the two 
amnions constitutes distinct cavity for each foetus. The septum is 
formed by the adhesion of the two amnions (Fig. 405). 




Fig. 405. — Distinct sacs: amniotic septum. 

3. Fusion. — The placenta is common, as well as the circulation. 
The two foeti are situated in a single cavity and float in the same 
liquid; there is only one chorion and one amnion (Fig. 406). 

Symptoms. — Interrogation. — Exaggeration of the malaise of preg- 
nancy ( ?). Sensation of the foetal movements over a great extent of 
the abdomen, or in two regions clearly separated from each other. 



354 Multiijle Pregnancy, 

Inspection, — Exaggeration of the size of the abdomen in relation 
to the epoch of the pregnancy, as in hydramnios. Subpubic oedema, 
with or without oedema of the lower limbs, as in hydramnios. 

Palpation. — Continued tension of the uterine wall, rendering ex- 
ploration of the uterine contents difficult. Frequent depression of 
.the fundus of the uterus, and vertically on the median line of the 
anterior face of the uterus (Herrgott). Palpation permits the dis- 
covery of two foeti, the different parts of which are recognized, as in 
simple pregnancy. Sometimes the four foetal poles are easily per- 
ceived ; sometimes three, or only two, are clearly perceptible, ac- 
cording to the different attitudes of the foetus. 

Auscultation. — The rule, if both foeti are living, is, that there 
exist two foci of auscultation in relation with the situation occupied 
by the cardiac zone of each child ; exceptionally there exists only 
one focus, the situation of one foetus interrupting the perception of 
its heart sounds. 




Fig. 406. — Fusion of the two sace. 

Digital examination, — When there is a vertex presentation, the 
ballottement is less clear and perceived with greater difficulty than 
in a simple pregnancy. In hydramnios the opposite is the case. 
Complete or incomplete effacement of the cervix before accouche- 
ment is frequent, as in hydramnios, in any over- distention of the 
uterus during pregnancy. 

The diagnosis should especially differentiate from hydramnios. 
The distinctive signs are the palpation and auscultation of a single 
foetus, the extended fluctuation in hydramnios and the perception 
of numerous small foetal parts in twin pregnancy. 

B. Accouchement, 

a, Eutocia. — The first accouchement occurs as in a simple preg- 
nany. After the expulsion of the first child it is necessary to place 
two ligatures on the cord, one foetal, the other maternal, to avoid the 



Multiple Pregnancy, 355 

haemorrhage from the maternal end, as it would be fatal to the 
second child in case of a common circulation. 

The time which separates the first accouchement from the second 
is usually a quarter of an hour ; it may be shorter or longer, and 
lasts for eight or ten hours and even more. In fact, when, the two 
foeti being completely distinct, one foetus has been expelled before 
term and with its appendages, the cervix may close and pregnancy 
continue its course to normal term, at which moment the second 
foetus remaining intact will be expelled as in the case of simple 
pregnancy. 

The second accouchement is reduced to the period of expulsion, 
for the dilatation being complete after the passage of the first child 
the second has only to traverse the open genital passage. The 
second foetus will be preceded or not by a bag of waters, according 
as the amniotic cavity was single or double. Tins second accouche- 
ment is generally rapid. 

The delivery of the appendages takes place after the expulsion of 
the two foeti, the two placentae, united or separate, being expelled 
as a whole, as after simple accouchement. Exceptionally, the 
appendages of the first child may be expelled before the second 
accouchement. This delivery should be favored only in case the 
placenta is engaged in the vagina or occupies the passage which the 
second foetus must follow. 

h. Dystocia. — The dystocia may be of maternal or foetal origin. 

Maternal dystocia. — The various maternal complications (ec- 
lampsia, haemorrhage, rigidity of the cervix, etc.) will be treated as 
in the case of a simple accouchement. 

After the first accouchement, if the second delays, at the end of 
what time is it necessary to interfere ? In case of pressing danger 
for the mother (haemorrhage) or for the child (retardation of the 
cardiac pulsations) the accouchement should be terminated at once. 
In the contrary case, if the presentation is that of the vertex or of 
the breech, and if the cervix does not close, an hour's time should 
be allowed nature to act spontaneously, but if after an hour, delivery 
does not take place it is necessary to interfere and extract the child, 
for a longer delay offers no advantage and may be prejudicial for 
the child. 

Exception : However, we are authorized not to interfere, even 
after an hour, when the three following conditions are united: 

1. First ovum completely expelled (that is with its appendages). 

2. Expulsion of the first ovum before term. B. Mother in good 
condition. In these conditons, in fact, the pregnancy is capable of 
continuing to normal term and of permitting the ulterior develop- 
ment of the second foetus without danger to the mother. 



356 



Multivle Pregnancy. 



Foetal dystocia. — This dystocia will vary with the relative situation 
occupied by the two foeti. 

1. Foeti in 9 9. — The two heads may have a tendency to engage 
simultaneously at the superior strait. The head least engaged 
should be pushed back to permit the descent of the other. 

2. Foeti in 6 6. — The difficulties arise in extraction, on account of 
the number of feet the hand may meet. Only one foot should be 
drawn on. 

3. Foeti in 6 9 or m 9 6. — a. If the first foetus presents by the vertex 
it is seldom that the accouchement presents any difficulty. 




Fig. 407. — Cephalic locking (Budin). 

h. When the first foetus presents by the breech, difficulties arise 
at the moment of the passage of the head. This cephalic extremity 
is arrested by the head of the second (Fig. 407). The indications 
are, to attempt successively : 1. To push up the head of the second 
foetus to permit the extraction of the first. 2. To apply the forceps 
on the head of the second foetus ( ?). 3. Craniotomy on the head of 
the second foetus, only in case it is supposed to be dead. 4. If the 
second foetus is living, as the existence of the first is very much 



Multiple Pregnaney, 



857 



compromised by the situation in which it will remain some time, 
to resort to craniotomy or to decapitation of the first child in order 
to allow the extraction of the second child alive. 

4. Fceti antero-posterior. — Same difficulties possible as in the first 
case, foeti in 9 9. 

5. Fueti in T. — The only difficulty will be with regard to the 
second child which may present by the abdomen or by the thcrax. 
Version by internal manoeuvres after the birth of the first child. 

6. Foeti in j^ inverted. — Three cases may be observed : 

1. The first foetus presents transversely and completely obstructs 
the superior strait. The first child should be extracted by version, 
or, if necessary, by embryotomy. If the second foetus is easily 
accessible its extraction should first be attempted before resorting 
to embryotomy. 

Then the second child, being insinuated between the first child 
and the uterus, thus descends to present, first, either by the vertex 
(second case) or by the breech (third case). 




Fig. 408. — Locking of the foeti (Jacquemier). 

2. By the vertex. — The shoulder of the child which presents by the 
vertex may be arrested by the neck of the foetus placed transversely 
(Fig. 408). The indications are, to attempt successively : 1. To 
liberate the shoulders, if the introduction of the hand is possible. 

2. To extract with the forceps the child which presents by the vertex. 

3. To perform either craniotomy of the head wliich presents, or 
decapitation of the other foetus, according to the relative facility of 
the operations, and according to the chances of fife pertaining to 
one or the other child. To extract by internal version the child 
remaining in the uterus. 

3. By the hreech. — Possible locking of the head of the child en- 
gaged with the neck of the foetus (Fig. 409). The indications are, to 



358 



Multiple Pregnancy. 



attempt successively : 1. To liberate the engaged head with the 
hand. 2. To perform decapitation of one or the other child, indif- 
ferently, unless the foetus remaining in the uterus is not dead. Then 
decapitation of the foetus half expelled will be preferred, on account 
of the greater facility of the operation and the small chance of ex- 
tracting the child living. The child placed transversely is brought 
down by internal version. 

7. Fceti in hammock. — Spontaneous delivery is impossible. The 
two children will be successively extracted by internal version. 




Fig. 409. — Locking of the fceti (Penard). 

II. Three to five children at a birth — These pregnancies 
are extremely rare. Their diagnosis is possible before labor (Pinard). 
The knowledge of the difficulties that have drawn our attention to 
double accouchements permits us to surmount the causes of dystocia 
that may be met in these exceptional cases. 



Premature Expulsion. 359 



CHAPTER XXIV. 



PREMATURE EXPULSION. 

. Premature expulsion is that which takes place before the normal 
term of the pregnancy, that is, before nine months, counting from 
the moment of conception. During the first six months (180 days) 
it is designated as abortion, and during the last three as premature 
accouchement. According to the epoch at which it takes place 
abortion is distinguished as embryotic (first three months) and foetal 
(second three months). 

Pathogeny and cetiology. — In the pathogeny of premature expulsion 
three principal factors are admitted : 

The ovum (appendages and foetus) (pathological state or death). 

The uterus (contractions of the uterine muscular structure). 

Any foreign body occupying the ovulo-uterine space (haemor- 
rhages, sounds, etc.). 

But whatever the pathogenetic factor that acts primarily, and 
whatever may be the origin of the accident, it is upon uterine con- 
traction that the principal role devolves, that of the efficient cause. 
Aside from this single efficient cause there are numerous determin- 
ing causes that we shall study as follows : 

I. Non-traumatic causes. 

A. Father. 

1. Extra-genital causes. — Any cause which is capable of producing 
debility or enfeeblement of the organism may interupt the ulterior 
development of the ovum. Such are : advanced age, precocious 
senility, abuse of sexual relations, various diseases (tuberculosis, 
albuminuria, diabetes, and syphilis especially), various poisons, as 
lead, tobacco, alcohol and sulphide of carbon. 

2. Genital causes. — These are essentially local, such as orchitis, 
prostatitis, urethritis, and strictures. 

B. Mother. 

1. Extra-genital causes. — Any cause of organic debility, whatever 
its source, may act as an interruption to the development of the 
foetus. 

Heredity. — In some families the women seem more predisposed to 
abortion than in others. A first abortion exposes to repetition, 
especially at a corresponding epoch of subsequent pregnancies. 



360 Premature Expulsion. 

Obesity is a cause of sterility and also of abortion. Very fat 
animals are bad breeders. 

Age. — At the two extremes of genital life the woman seems more 
often subject to abortion. 

Hygiene, alimentation. — A bad hygiene and an insufficient alimen- 
tation expose to interruption of pregnancy. 

Altitude. — Saucerotte states that women who live in the mountains 
of the Vosges are more exposed to abortion than those who live on 
the plains (?). 

Medicaments. — Certain drugs, such as ergot, rue, sabina, sulphate 
of quinine, salicilate of soda, etc., are reputed to have abortifacient 
properties. 

Chronic diseases. — The majority of chronic diseases (tuberculosis, 
albuminuria, diabetes, cancer) predispose to abortion by debilita- 
tion of the organism. Syphilis should be especially mentioned on 
account of its importance. Poisoning by lead, tobacco, alcohol and 
sulphide of carbon are also causes. 

Acute diseases. — Any acute disease, which acts violently on the 
organism, either by elevation of temperature or by disordered 
function, is capable of causing premature expulsion of the ovum. 
I only recall the principal ones, cholera, typhoid fever, eruptive 
fevers, intermittent fevers, cardiopaths, incoercible vomiting, etc. 

Epidemic abortion. — Among animals, especially among cows, there 
sometimes exists an epidemic of abortions which attacks all the 
females of one stable or of. one locality. Nocard has shown that 
this is due to a microbe acting on the genital organs and trans- 
mitted from one animal to another. Antisepsis arrests the epi- 
demic. Hervieux has attempted to demonstrate that pregnant 
females brought in contact with puerperal septicaemia are also pre- 
disposed to abortion, but the proof is not positive. 

2. Genital causes. — These may be periuterine, uterine, or intra- 
nterine. 

Periuterine. — Any obstacle to the devolopment of the uterus 
^abdominal tumors, especially ovarian cysts, adhesions left by a 
previous pelvic peritonitis) may cause premature expulsion of the 
ovum. 

Uterine. — The same is true of the majority of uterine diseases 
congestion, metritis and endometritis, deviations, fibroids, cancer). 
At an epoch corresponding to each menstruation there occurs a 
congestive impulse, which predisposes to abortion. Any genital 
excitation may, by inducing congestion or uterine contractions, 
favor premature expulsion. 

Intra-uterine. — We shall take into question here the effusions of 
blood, which may occur between the ovum and the uterine wall, 
that is to say, utero-ovuline haemorrhages. These haemorrhages. 



Premature Expulsion. 



361 



which have their source in the uterus, are, exceptionally, produced at 
the level of the membranes (utero-membranous haemorrhages), but 
almost always in a corresponding zone of the placenta (utero- 
placental haemorrhages). According as the blood remains im- 
prisoned in the uterine cavity, or flows out without remaining in the 
uterus, or as these two conditions are united, the hsemorrhage is 
called internal (Fig. 412), external (Fig. 413) or mixed (Fig. 414). 
The result of these haemorrhages varies according to the abundance 
and the extent of the placental detatchment, but they usually cause 
premature expulsion of the ovum. 




Fig, 412. — Internal 
haemorrhage. 



Fig. 413. — External 
haemorrhage. 



Fig. 414. — Mixed 
haemorrhage. 



C. Ovum. 

1. Appendages. 

Placenta. — Degenerations of the placenta, when they are marked 
cause the death of the foetus and abortion. Yicious insertion some- 
times terminates in the same result. 

Membranes. — Expulsion of the ovum usually follows rupture of ttie 
membranes after a brief delay. 

Liquor amnii. — Hydramnios, when it is very marked, and es- 
pecially the acute form, is a possible cause of abortion and of pre- 
mature accouchement. 

2. Foetus, — Any cause that produces the death of the foetus is also 
a cause of its premature expulsion. Monstrosities act in the same 
direction. With regard to multiple pregnancy, it often produces, 
by excess of uterine distention, expulsion before term, but premature 
accouchement rather than abortion. 

II. Traumatic causes 

A. Mother. 

1. Extra-uterine causes. — Any traumatism on a region distant 
from the genital sphere may be the cause of premature expulsion of 



362 , Premature Expulsion. 

the ovum. I have already spoken of surgical operations and of 
their influence on the progress of pregnancy. 

2. Genital causes. — Periuterine. — Any traumatism affecting the 
abdominal wall is capable of causing premature expulsion of the 
ovum. A prolonged compression of the abdomen may produce the 
same result. 

Uterine. — Any traumatism acting on the cervix, operation, cauteri- 
zation, digital exploration, vaginal injection with too much force or 
sexual excess, may be abortive. 

Tntra-uterine. — Any foreign body penetrating between the uterus 
and the membranes, accidentally or voluntarily (therapeutically or 
criminally), causes detachment to a certain extent and usually 
provokes premature expulsion. 

B. Ovum. 

1. Appendages. — The same traumatism which detaches the mem- 
branes may rupture them. Its abortive action in such cases is still 
more certain. 

2. Foetus. — The action is the same if the instrument which has 
perforated the membranes attacks and wounds the foetus. 

Such are the multiple causes and in spite of their number it often 
happens that the physician finds difficulty in seeking the origin of 
the premature expulsion. 

Pathologicel anatomy and symptomatology. 

a. First three months.— Embryonal abortion (Fig. 416). — I shall 
take as a type for description the abortion which occurs at the 
middle or at the end of the secondmonth reserving some final 
words for that of the first and third month. 



f f J 

Fig. 415. — Ovum expelled as a whole (no efFacementJ ABC. 

The woman has had a menstrual suppression and has perceived 
various sympathetic phemomena; she suspects pregnancy. Then 
follows a genital haemorrhage, simulating a simple return of the 
menses, or colic caused by painful uterine contractions. Whatever 
may be the beginning, pain or flow of blood, these two symptoms 
are very soon united and continue together. Local examination 
shows a certain softening of the cervix, and an increase in the size 



Prema ture E.xpu Is ion . 



363 



of the body of the uterus accompanied by tension of the contiguous 
tissues. The external orifice of the cervix is sometimes closed and 
sometimes open and occupied by the ovum. The ovum is generally 
expelled as a whole, and in a single stage, into the interior of the 
vagina. It traverses the cervix by opening successively the isthmus, 
the cervical canal and the external orifice, but without producing, 
properly speaking, effacement. 












Fig. 418. — Ovum expelled, in three stages (no effacement). ABC, expulsion of 
the embryo ; D E F, expulsion of the appendages less the decidua ; G H I, expulsion 
of the decidua. 

After the expulsion of the ovum, the pain subsides and the haemor- 
rhage diminishes. During some days there is a sero-sanguinolent 
flow, becoming mucous finally. In three to four weeks the uterus 
has regained its normal size. 

During the first month of pregnancy the condition of gestation 
is often ignored and abortion occurring at the menstrual period is 
frequently mistakexi for the monthly flow, the ovum being expelled 
unnoticed. 



364 Premature Expulsion. 

During the third month the abortion resembles that of the second 
month with the difference that the ovum being large the pains and 
haemorrhages are more marked. 

h. Second three months (Fig. 418). — Here I shall also take as a 
type abortion occurring in the middle of this period, that is to say 
during the fifth month. 

Pregnancy has become quite probable, sometimes even certain, 
when one of the three following symptoms occur to mark the be- 
ginning of the abortion : 

A sudden loss of amniotic liquid. 

A genital haemorrhage. 

Uterine colic, with its usual characteristics. 

Pain and haemorrhage soon appear, when they have not been the 
initial phenomena and continue with variable intensity until the 
accident has terminated or has been avoided. Touch combined with 
palpation, permits us to detect the characters proper to the gravid 
uterus and to follow the expulsion of the fcetus, which usually occurs 
in the following manner : 

First stage. — Expulsion of the foetus. 

Second stage. — After a variable time, expulsion of the ap- 
pendages less the decidua. 

Third stage. — Expulsion of the decidua as a whole or in sections. 

It sometimes occurs that the decidua is expelled at the same 
time with the appendages, so that the abortion is completed in two 
stages. However, expulsion of the ovum in three stages and the 
non-effacement of the cervix may be considered as the two char- 
acteristics of abortion at this period. 

The duration of the expulsion is quite variable, it extends from 
some hours to several days. The pains and the haemorrhages cease 
after the complete evacuation of the uterus. A lochia! discharge of 
some days occurs and in three to four weeks the uterus has re- 
turned to its normal size. 

c. Third three months, — Premature accouchement. — Premature ac- 
couchement is an exact copy of accouchement at term, and, like it, 
occurs in two stages : the first, for the expulsion of the child, and the 
second for the delivery of the appendages. The puerperal state is 
the same in both cases and of about the same duration (Fig. 427). 

Anomalies of the delivery of the appendages. — Before placental de- 
velopment there may be observed more or less complete retention 
of the ovuline envelopes which are finally eliminated in sections. 
When the placenta is distinct various conditions may occur: 

1. Sometimes the placenta is completely detached from the 



Premature Expulsion. 



365 



uterine wall and elimination takes place, after a variable time, 
either as a whole, or by section, with the possible accompaniment 
of septicaemic accidents. 

2. Sometimes the placenta is partly adherent and partly detached ; 
the retention in such cases may be prolonged. The detached part 
becomes necrotic and is eliminated in fragments, while the adherent 
part continues to live as a parasite on the uterine wall, becoming 
the source of obstinate haemorrhages which necessitate intervention. 

3. The placenta sometimes remains totally adherent to the 
uterus. After a prolonged retention without accidents, the placenta 
may be expelled as a whole. In place of this, its expulsion in 
several fragments of variable volume may be observed. Finally, in 
some exceptional cases, absorption of the retained placenta has been 
observed. 




Fig. 427. — Ovum expelled in two stages. A^^ W^^ expulsion of the foetus; 
Q^^, expulsion of the appendages (efFacement). 

Complications. — Septicaemia, localized (pelvic peritonitis) or gen- 
eralized, is frequently observed as a consequence of abortion, es- 
pecially when there is retention of a part or of the whole of the 
appendages. 

Uterine licemorrhage may precede, accompany or follow the ex- 
pulsion of the ovum. The loss of blood is sometimes so grave that 
it causes syncope and even the death of the woman. 

Tetanus, — This complication, although very exceptional, has been 
observed a certain number of times in consequence of abortion. 

1. Premonitory treatment. — A woman having had a series of preg- 
nancies terminated by premature expulsion, and is again pregnant, 
what should be done to avoid a repetition of the accident? All 
supposed causes of premature expulsion must be treated. In the 
absence of the various known and clearly derminable causes there 



366 Premature Expulsion, 

are pregnancies in which the interruption seems to he due to irri- 
tability or to congestion of the uterus, these two states terminating 
in exaggerated contractions of the uterine muscle and in premature 
expulsion of the ovum. Irritability is recognized by the facility 
with which painful contractions of the organs are produced and will 
be combatted by absolute repose in bed during a variable time. The 
use of opiates and of viburnum prunifolium and the absence of 
sexual relations are also to be recommended. Uterine congestion 
is to be treated by rest in the horizontal position, by intestinal lax- 
atives and, if the woman is plethoric, by repeated bleedings of 200 
to 300 grammes. 

2. Prophylactic treatment. — If there be a menace of premature 
expulsion, what treatment should be instituted to prevent abortion? 
For the execution of this prophylactic treatment absolute repose in 
bed is necessary. Either viburnum prunifolium or opiates ^^i\\ be 
administered. 

3. Curative treatment. 

a. Before expulsion. — The indications are for intervention only 
in case of accident. Haemorrhage is the principal and the most 
frequent complication. The best treatment to oppose to this is tam- 
ponnement of the vagina. In premature accouchement, the haemor- 
rhage being almost always due to a placenta praevia, the treatment 
for that condition is required. Ergot should never be given. During 
expulsion of the ovum care must be taken to avoid drawing on the 
part engaged in the cervix, as by this the ovum may be ruptured and 
a fragment retained that will be difficult to extract. During pre- 
mature accouchement the management is similar to that of labor 
at term. 

h. After complete expulsion. — If the case be one of premature ac- 
couchement, the management will be the same as in retention of 
the placenta in delivery at term. But if the pregnancy be less ad- 
vanced at the time of expulsion, and if there be a retention of the 
placenta, or, before its formation, of ovuline membranes, what 
should be the line of conduct ? In the absence of accidents (septi- 
caemia or haemorrhage) expectation with rigorous antisepsis is 
clearly indicated, for, in the great majority of cases, the expulsion 
of the membranes or of the placenta takes place spontaneously after 
some hours or some days. But if accidents follow, the danger be- 
comes pressing and it becomes necessary to interfere. Here the 
obstetricians are divided into two camps, the evacuators and the 
anti-evacuators of the uterus. 

The evacuators, in cases of haemorrhage or of septicaemia, after 
having dilated the cervical canal if necessary, draw the cervix down 
with the vulsellum and remove the placenta and the membranes 



Premature Expulsion, 367 

retained in the uterus, by the aid of the fingers, or the ovum forceps 
(Fig. 431), or by the curette. The intervention is terminated by 
intra-uterine irrigation and by intra-uterine tamponnement, if 
necessary. 



Fig. 431. — Ovum forceps. 

The anti-evacuator, dismayed by an intervention which they con- 
sider useless and dangerous, combat the haemorrhage by vaginal 
tamponnement and the septicaemia by frequent vaginal injections. 

Both these methods have their advantages and their dis- 
advantages, but in spite of the good results given by the latter 
procedure it offers less security. 

c. When the uterus is completely evacuated, regression occurs in 
a normal manner, except in case of complications analogous to 
those following after accouchement at term and which will be 
treated by similar methods. The woman should remain in bed the 
same length of time as after delivery at term. 



368 Accidents of Accouchement, 



CHAPTER XXV. 



ACCIDENTS OF ACCOUCHEMENT. 

Euptures and lacerations of the perinaeum, of the vagina, and of 
the uterus have already been discussed and we have here only to 
consider haemorrhages, procidence of foetal members and of the 
cord, subcutaneous emphysema and fractures. 

Haemorrhages. — Genital haemorrhages that occur during ac- 
couchement may proceed from the vulva^ from the vagina, from the 
cervix, or from the body of the uterus. They are traumatic or 
spontaneous. 

a. Vulvar hcemorrhages. — Traumatic causes : Any accidental or 
operative traumatism may produce a haemorrhage of variable im- 
portance, but usually slight unless a varicose vein has been opened. 

Spontaneous causes : Rupture of a varix may give rise to 
abundant haemorrhage. 

Treatment : Compression, forcipressure, sutures. 

h. Vaginal hcemorrhages. — The causes are analogous to those 
producing vulvar haemorrhage. These haemorrhages are quite ex- 
ceptional before the expulsion of the foetus and after accouchement. 
They often make a part of those of delivery of the appendages, 
which will be studied later. 

c. Cervlco-uterine hcemorrhages. — At the beginning of labor, and 
especially among the primiparae, the opening of the cervix produces 
a slight haemorrhage from the excoriations of the mucosa. Truly 
serious haemorrhages result from lacerations produced by the 
passage of the foetus. 

d. Hcemorrhages from the body of the uterus almost always depend 
upon a vicious insertion of the placenta. A placenta normally in- 
serted may sometimes furnish a certain quantity of blood by its 
detachment. But these haemorrhages are in general of too smaE 
importance to require special treatment. 

Procidence of foetal members and of the cord. 

a. Procidence of the cord. — The cord is said to be prolapsed when 
it is insinuated between the foetal part which presents and the wall 
of the genital canal. 

Frequency, one out of one hundred accouchements. 



Accidents of Accouchement. 369 

Pathogeny and cstiology .—In the normal state, the part of the 
foetus which presents exactly obstructs the genital canal, impedes 
the flow of the liquor amnii and the procidence of the cord. But 
if any cause obstructs this-eutocic adaptationihe liquor amnii and 
the cord obeying gravity and the uterine contractions are drawn 
toward the vagina and prolapse of the cord is thus constituted. The 
different causes capable of producing tliis result are the following : 

1. Ovum. 

a. Foetus. 

1. Small volume. 

•2. Presentation other than the vertex. 

3. Multiple pregnancy. 

4. Previous procidence of a member. 
h. Appendages. 

1. Hydr amnios. 

2. Placenta prsevia. 

3. Exaggerated length of the cord. 

4. Knots of the cord (?). 

5. Premature rupture of the membranes. 

2. Mother. 

a. Uterus. 

1. Absence of tonicity of the inferior segment. 
h. Pelvis. 

1. Pelvic deformities, or any cause preventing engage- 
ment of the foetal part. 

8. Obstetrician. 

1. Any intervention improperly performed is capable of 
causing procidence of the cord. 

Symptoms and diagnosis, — Two cases may present, one where the 
membranes are intact, the other where the bag of waters has broken. 

a. Intra- ovuline procidence. — Membranes intact. — When the cervix 
is not open, the cord is difficult to perceive with the finger through 
the uterine wall, but with a living child (pulsations of the cord) and 
very thin cervico-uterine segment, an experienced finger can some- 
times recognize the presence of the cord. In proportion as the 
cervix opens, the diagnosis becomes more and more easy, for the 
membranes oppose only a slight obstacle to digital exploration. 

b. Membranes ruptured. — Extra-ovidine procidence. — First degree, 
intra-uterine. The loop of the cord does not pass the external 
orifice. Second degree, intra-vaginal. The loop of the cord lies in 
the vagina, without opening the vulvar orifice. Third degree, intra- 
vulvar. The funicular loop projects through the vulva. Besides 
the foetal part that presents the exploring finger meets the cord 



370 



Accidents of Accouchement, 



which is recognized by its form and its consistency and, in cases 
where the child is living, by the pulsations that are felt by pressing 
it between the finger and a resisting plane. 

Prognosis. — Any arrest of the funicular circulation is the cause 
of prompt death of the foetus, which succumbs to asphyxia. Thus 
the procidence which exposes to compression is very dangerous for 
the foetus ; however, Depaul's estimation of seventy-five per one 
hundred of mortality appears somewhat exaggerated. 

The prognosis also depends : 

Upon the degree of the prolapse — the more pronounced it becomes, 

the more the foetus is exposed : 
Upon the presentation — the danger of compression being greater 

in vertex presentations ; 
Upon the epoch of labor — the more advanced the labor, the 

easier intervention becomes ; 
Upon the state of the membranes — with an intact bag of waters, 

it is rare to see procidence of the cord become fatal to the 

child; 
Upon the intervention. 




F[G. 432. — Reduction of the cord by the genu-pectoral position (Playfair). 

Treatment. — a. Three methods of intervention. 

1. Reduction of the cord. — By the position of the woman. The 
woman being placed in the genu-pectoral position (Fig. 432), the 
action of gravity is sometimes sufiicient to reduce the cord. 

By the use of the hand. The cord being seized by the extrem- 
ities of the fingers (Fig. 433) is returned to the uterus and, at need, 
hooked over a limb to avoid a new prolapse. For this purpose 
Mauriceau applies a sponge in the space through which the cord 
descends. 

By the use of an instrument (Figs. 434 to 438). In one case I 
used a simple long forceps to grasp the cord and to return it to the 
uterine cavity (Fig. 439). 



Accidents of Accouchement. 



371 




Fig. 433. — Reduction of the cord by the use of the hand. 




Fig. 434.-Lyre-shaped instrument for seizing the cord and liberating 

it after reduction. 



372 



Accidents of Accouchement, 





Fig. 435. — Double hook with mobile branches, permitting the cord 
to be seized and abandoned after reduction. 







FiG. 436. — Grasping hook of whalebone, composed of two handles 
with parallel movement. 



Accidents of Accouchement. 



378 





Cj 



Fig. 437. — Ordinary sound with stylet. 




Fig. 438.— Small fork of metal or wood made on the spot, if necessary. 



374 



Accidents of Accouchement, 



2. Podalic version has been advised; either by mixed or by 
external manoeuvres before complete dilatation, hoping that this 
will reduce the prolapse, or in case of not reduction that the prog- 
nosis will become less grave with a presentation of the breech; or 
by internal manoeuvres, when dilatation is complete, to terminate 
accouchement. 

3. Forceps. — The application of this instrument with complete 
dilatation is also advised. 




Fig. 439. — Simple long forceps. 

h. Clinical use of these different methods. — If the cormic ovoid 
presents (breech, thorax, abdomen), the management during the 
period of dilatation will be the same as if the funicular procidence 
did not exist, for attempts at reduction are almost useless, as the 
cord again prolapses and besides the danger is relatively small. 
After complete dilatation, in breech presentation, the pulsations 
must be watched and extraction made if danger occurs. 

If there be a presentation of the cephalic ovoid two cases may 
exist : 

If the dilatation is complete, the accouchement must be promptly 
terminated by version or by the forceps. 

If the dilatation is incomplete, reduction of the cord should be 
attempted by the use of the methods already described. If these 
procedures fail, and if the foetus is in danger, pelvic version, by ex- 



Accidents of Accouchement, 375 

ternal or by mixed manoeuvres, should be essayed, with or without 
anaesthesia. Finally, as soon as dilatation becomes sufficient, the 
child must be delivered promptly, 

c. Procidence of foetal membranes (Fig. 440).— Frequency, one per 
one hundred. The causes and the pathogeny are the same as those 
given for prolapse of the cord. There exist three degrees in the 
procidence of the foetal members. 

First degree — hand, foot. 
Second degree — forearm, leg. 
Third degree — arm, thigh. 

The third degree is very rare and can only exist as a consequence 
of tractions exerted by the accoucheur. 




Fig. 440. — Procidence of the left superior member. 

Treatment. — 

Membranes intact. — Simple expectation. 

Membranes ruptured. — When the dilatation is sufficient to permit 
access, attempt may be made to push up the prolapsed member with 
the extremities of the fingers. If reduction is impossible, complete 
dilatation is awaited and if expulsion is still prevented recourse is 
had, according to the case, to version or to the forceps. In vertex 
presentation, the forceps will be slipped between the head and the 
prolapsed member and extraction performed as if the procidence 
did not exist. 



376 Accidents of the Delivery of the Appendages, 

Subcutaneous emphysema and fractures. 

Under the influence of the excessive exertions made by the woman 
during the period of expulsion there have been, noted, as patho- 
logical curiosities, fractures of the sternum and subcutaneous 
emphysema. Usually the emphysema is not grave, but it may 
however, cause the death of the patient. 



CHAPTER XXVI. 



ACCIDENTS OF THE DELIVERY OF THE 
APPENDAGES. 

The accidents which may complicate the delivery of the ap- 
pendages are usually divided into general and local. 

The general accidents relate to those affections which attack the 
organism in general at this period, such as, convulsions, syncope, 
asphyxia, etc. The only indication for their treatment is to termi- 
nate delivery as promptly as possible. 

Aside from these general accidents, which we cannot study here 
in detail, there are numerous local complications that become of 
first importance in obstetrics. 

These local accidents that occur at the moment of delivery of the 
appendages may be grouped as follows : 

I. Eetention of the appendages of the ovum. 
II. Haemorrhages. 

III. Treatment. 

I. Retention of the appendages of the ovum. 

Divisions^ definitions. — Eetention may be : 

1. Total : that is, of all the appendages. 

2. Partial: of a part of the placenta; of the membranes as a 
whole ; of a part of the membranes. 

Eetention of the membranes seems at first difficult to define. 
When, ten or twelve hours after accouchement, the placenta and 
the membranes are still in the uterus the diagnosis is not difficult 
to establish, but when, after the expulsion of the foetus, their de- 
livery delays, we find it difficult to state precisely the exact moment 
at which the physiological state gives place to the pathological state, 
that is, to retention. 

This difficulty, however, does not apply to the isolated retention 



Accidents of the Delivery of the Ajypendages. 



377 



of the membranes, which exists whenever, after the expulsion of the 
placenta, part of the whole of their extent remains in the uterus, but 
only relates to retention of the placenta. 

Now it may be said that there is a retention of the placenta when- 
ever the internal orifice (uterine circle, or an orifice accidentally 
formed in the uterus) is sufficiently closed and rigid to prevent the 
passage of the placenta or that of the hand that seeks to extract it. 
It is then the internal orifice, or an accidental orifice, which affords 
the measure of retention of the placenta. 

But to what degree must this orifice be closed to cause retention? 
A mathematical answer is impossible. The orifice must return on 
itself to a degree sufficient to constitute an obstacle to the passage 
of the placenta, or to the hand of the accoucheur. It is then the 
placenta (or better, the hand, since it requires a larger opening) 
which gives the measure, the criterion. I recognize that this lacks 
precision, but we must be content with it for want of a better 
standard (Figs. 441, 442, 443). 




Fig. 441. — No retention. 



Fig. 442. — Limit. 



Fig. 443.— Retention. 



Symptoms and diagnosis* — 

1. Total retention of the appendages. — This total retention will be 
recognized, when, in digital examination, a certain time after ac- 
couchement, one finds the internal orifice, or uterine circle, into 
which passes the cord (unless it has been separated), sufficiently 



378 Accidents of the Delivery of the Appendages. 

closed and rigid to prevent the passage of the placenta and of the 
hand, if it is necessary to introduce it. 

Closed and rigid are the two indispensable conditions of retention, 
for with a closed but supple orifice retention does not exist, dila- 
tation being possible without difficulty under the influence of a 
mechanical dilatation (traction on the placenta, or the introduction 
of the hand). 

2. Partial retention of the appendages. — The diagnosis will be made 
by the examination of the appendages expelled and of the woman. 

a. Retention of the placenta. — Total retention of the placenta is not 
observed without simultaneous retention of the membranes. We 
have then to note only partial retention of the placenta, of a de- 
tached cotyledon, or of an accessory cotyledon. By examination of 
the appendages it will be perceived that a part of the placental sub- 
stance is wanting when on the uterine surface there is a depressed, 
ragged region. However, with a placenta that has been torn during 
extraction the diagnosis may be difficult. The retention of an 
accessory cotyledon is recognized by the existence of two vessels 
running in the same direction on the membranes and suddenly in- 
terrupted at the place of rupture of the ovuline envelopes. In case 
of doubt, the introduction of the hand into the uterus and the ex- 
ploration of the cavity permits us to discover and to secure the 
retained cotyledon, which is generally adherent. 

h. Retention of the membranes. — The isolated retention of the mem- 
branes is easily discovered by examination of the expelled ap- 
pendages, when it is complete or extended; but in cases where it is 
only constituted by a simple fragment the diagnosis will sometimes 
be doubtful. This retention will be suspected when in attempting 
to reconstruct the membranes in the position that they occupy in 
the uterus this cannot be completely arrived at. In exammation 
of the patient the fingers will seek a floating membrane, the 
presence of which will leave no doubt as to the diagnosis. Eetention 
may also exist without the membranes being accessible, when, for 
example, they are completely enclosed in the uterus. 

Progress and complications. — Eetention of the membranes pro- 
duces no immediate accident, but may be, during post-partum, the 
cause of haemorrhages, of septicaemia, or of after-pains. 

Partial or total retention of the placenta sometimes becomes the 
source of the same accidents, but with a much greater degree of 
frequency and of gravity. In the absence of complications this 
retention may last a variable time, from several hours to several 
days. The placenta is then expelled by a new labor, as a whole, or 
in successive fragments. 

Prognosis.— The prognosis of isolated retention of the membranes 
is generally benign, on condition that a rigorous antisepsis shall be 



Accidents of the Delivery of the Appendages. 379 

observed during post-partum. Spontaneous expulsion is the rule. 
That of placental retention is more serious for the patient is exposed 
to septicaemia and sometimes to grave haemorrhage. Thus we shall 
see, apropos of the treatment, that it is necessary to interfere in 
retention of the placenta, while expectation is the best method for 
that of the membranes. 

Etiology. — 

1. Uterine inertia, consecutive to accouchement, prevents the 
detachment of the placenta and its expulsion. Uterine inertia is 
especially a cause of dangerous haemorrhage and will be studied at 
greater length with this accident. 

2. Uterine spasm. — Spasm of the external orifice has been wrongly 
admitted ; that of the internal orifice (uterine circle), or of an orifice 
of new formation, placed above the preceeding, has alone been 
proven. 

(a). Spasm of the internal orifice. — When the placenta is completely 
above the internal orifice we designate the condition as encystment, 
when it is more or less engaged in this orifice, incarceration. 

1. Encystment may exist : 

With a total spasm of the uterus (Fig. 444). 

With a spasm of the internal orifice alone (Fig. 445). 

With an irregular spasm of the body of the uterus (Fig. 446). 




Fig. 444.— Total Fig. 445.— Spa^m of the Fig. 446.— Irregular 

spasm. internal orifice. spasm. 

2. Incarceration may be : 

Pronounced (Fig. 447). 

Median (Fig. 448). 

Slight (Fig. 449). 

(b). Spasm of an orifice of neoformation.— In the interior of the 
uterus, above the internal orifice or uterine circle, there is formed, 
either by paralysis of the uterus at the placental formation, or by 
contraction of an annular and limited region of the uterine muscle, 



380 



Accidents of the Delivery of the Appendages, 



a narrowed portion dividing the cavity of the body of the uterus 
into two cells, the superior containing the placenta (Figs. 450 and 






Fig. 447. — Pronounced 
incarceration. 



Fig. 448. — Median 
incarceration. 



Fig. 449. — Slight 
incarceration. 



450 his). This form of retention may present the same varieties 
of encystment and of incarceration as imprisonment, that is : 





Fig. 450 and 450 dis. — a 3, orifice of neoformation (spur of bifid uterus); 
c d, internal post-partum orifice (uterine circle). 

1. Encystment may exist: 

With total spasm of the body (Fig. 451). 
With spasm of the neo-orifice (Fig. 452). 
With irregular spasm (Fig. 453). 

2. Incarceration may be : 

Pronounced (Fig. 454). 
Median (Fig. 455). 
Slight (Fig. 456). 

3. Uterine rupture, with or without passage of the placenta into the 
peritonaeal cavity is a cause of retention. 

4. Uterine malformation. — Bifidity, obstructing the retraction after 
accouchement, may favor the retention of the placenta and of the 
membranes. 



Accidents of the Delivery of the Appendages. 



381 





Fig. 451. — Total spasm. Fig. 452.— Spasm of the 

neo-orifice. 





Fig. 453. — Irregular 
spasm. 




Fig. 454. — Incarceration 
pronounced. 



Fig. 455. — Incarceration 
median. 



Fig. 456. — Incarceration 
slight. 



5. Uterine tumors. — Any tumor, for example, a fibrous polj^pus, 
by obstructing the passage of the placenta, is capable of preventing 
the expulsion of the appendages (Fig. 457). 

6. Tumors of the vulva and vagina. — The same obstacle may some- 
times be caused by a tumor of the vagina or vulva. 

7. Excess of the volume of the placenta. — This excess of volume 
may be due to the size of the placenta itself, to the addition of clots 



382 Accidents of the Delivery of the Appendages. 

adhering to its uterine surface, or to the super- distention caused by 
the blood contained in the organ itself. The larger the placenta, 
it will be understood, the greater becomes the difficulty in passing 
the uterine circle. 




Fig. 457. — Uterine fibroma, obstructing the passage of the placenta. 

8. Adhesions of the placenta. 
Varieties : 
a. Extent. 

Partial adhesion. 
Total adhesion. 
h. Degree : three. 

Simple exaggeration of the physiological and normal state that 
the uterus is capable of overcoming, in most cases, by contracting 
with energy. 

More intimate adhesions, and such that only the introduction of 
the hand into the uterus can separate, the connections uniting the 
placenta to the uterine wall. 

Veritable fusion. — It is impossible to detach the placenta with the 
hand, and in post-mortem it becomes necessary to use the knife to 
separate it from the uterus, so intimate is the fusion. 

Ai]tiology. — 

Utero-placental inflammation. — Leading to a vertible sclerosis 
that unites the placenta to the uterus by fibrous tissue. 



Accidents of the Delivery of the Ajpj^endages. 



383 



Utero-placental haemorrhage. — The clot which forms between the 
placenta and the uterus unites these organs by its transformation. 

Exaggeration of the physiological adhesion.— The supposition is 
advanced, without explaining its mechanism, that the marked ad- 
hesion which exists at the fifth to the sixth month has persisted to 
term. 

9. Accessory placenta. — The existence of an accessory placenta, 
still adherent or detached (Fig. 458), is a cause of retention. The 
cotyledon, thus isolated, remains in the uterus with a more or less 
considerable section of the membranes. 




Fig. 458. — Retention of an Fjg. 459. — Partial retention Fig. 460. — Retention of the 
accessory cotyledon. of the membranes of membranes by a clot. 

adhesions. 

10. Mtdtiple pregnancy. — In multiple pregnancy the placenta, by 
its size or by the existence of two lobes, predisposes to retention. 
With this last disposition, the two placental masses being separated, 
the last to be expelled acts in relation to the first like an accessory 
placenta. 

11. Adhesion of the membranes. — The adhesion of the membranes 
may be of variable extent. Sometimes the decidua alone is ad- 
herent, sometimes the decidaa and the chorion, finally the three 
membranes may be united. The causes are inflammation of the 
membranes, haemorrhage of pregnancy, and, with regard to the de- 
cidua, the persistence of physiological adhesion. These adhesions 
cause the retention of a more or less considerable section of the 
membranes (Fig. 459). 



384 Accidents of the Delivery of the Appendages. 

12. Clot. — A blood clot enclosed in the membranes is sometimes 
retained at the internal orifice and prevents the exit of the ovuline 
envelopes (Fig. 460). 

13. Untimely traction on the membranes.— Hoo strong tractions on 
the membranes during their exit may cause their rupture and favor 
retention. 

14. Fragility of the cord. — A too fragile cord breaks under traction 
and, by impeding ulterior tractions, thus facilitates retention. 

15. Vicious insertion of the cord. — The insertion of the cord at the 
edge of the placenta, or on the membranes, exposes to funicular 
rupture at that point and to the danger of retention. 

16. Shortness of the cord may cause its rupture and the same con- 
ditions as above. 

17. Accouchement in the upright position, by causing rupture of the 
cord at the moment of expulsion of the child, exposes in the same 
way to ulterior retention of the appendages. 

18. Untimely tractions on the cord sometimes terminates in 
rupture and the unfortunate results that we have seen above. 

II. Haemorrliages of delivery of the appendages. 

Definitions and divisions. — In the same way that continuance of 
the appendages in the uterus for a certain time after accouchement 
is the rule, so the flow of a certain quantity of blood at the moment 
of delivery of the appendages is also normal and physiological. 
But when does this haemorrhage cease to be physiological and when 
does it become pathological? In the same way that it is impossible 
to answer mathematically as to retention, so it is useless to try to 
give in grammes the quantity of blood which should be lost to con- 
stitute a pathological state. The best definition is the following: 
A haemorrhage of delivery of the appendages becomes pathological 
when it compromises the woman's health. 

This haemorrhage, whether it precedes, accompanies or follows the 
expulsion of the appendages, may be internal, external, or mixed. 
These divisions have a practical importance, for they show the 
gravity of the haemorrhage should not be judged solely by the quantity 
of blood which escapes from the vulva. 

jEtiology. — 1. Uterine inertia. — The detachment of the placenta 
leaves the vascular uterine surface bare and all the vascular orifices 
gaping. If the uterine muscular structure does not contract at this 
moment, to energetically close all the vessels, a haemorrhage of a 
severity in proportion to the degree of the uterine inertia will be 
the consequence. 

2. Lacerations and ruptures of the uterus, — Any solution of con- 
tinuity affecting the cervix or the body of the uterus may cause 
haemorrhages of variable gravity. Eupture of the uterus may be 
combined with inertia. 



Accidents of the Delivery of the Appendages. 385 

3. Uterine inversion, of which we may have three degrees, mtra- 
nterine (Fig. 461), intra- vaginal (Fig. 462) and extra-vulvar (Fig. 
463), produces a persistent haemorrhage, which may become grave 
by its abundance or by its duration. 




Fig. 461. — Intra uterine inversion. 

4. Lacerations of the vulva and of the vagina, by affecting important 
vessels, may be the cause of a more or less serious haemorrhage. 

5. Vicious insertions of the placenta expose to haemorrhages during 
delivery of the appendages, for, after detachment of this organ, the 
inferior segment, where it was inserted, returns on itself less easily 
than the superior, on account of its relative poverty of muscular 
fibres. 

6. Retention of the appendages. — Every retention, partial or total, 
of the appendages, may become the source of haemorrhage by ob- 
structing the retraction of the uterus. 

III. Treatment of the accidents of delivery of the 
appendages. 

1. The retention exists alone. — The retention may be total or partial. 

a. Total retention. — When an hour after accouchement delivery 
of the appendages is not yet accomplished, we are authorized to 
make digital examination to ascertain the state of the parts and of 
the internal orifice. There are two elements that must be noted 
before any intervention : 

The state of the internal orifice (recognized by touch). 



386 



Accidents of the Delivery of the Appendages. 




Fig. 462. — Intra-vaginal inversion. 




Fig. 463. — Extra vaginal inversion. 



Accidents of the Delivery of the Appendages. 387 

The situation of the placenta (determined by touch, and presumed 
from the distance of the funicular ligature from the vulva). 

1. If the placenta is at the level of the internal orifice, whatever 
may be the permeability of this opening, the indications are to 
express, to draw, and to wait; at the end of a variable time the 
placenta detaches, then it becomes accessible to the finger, engages 
in the cervical canal and will be expelled. Success is only a question 
of patience. 

2. If the placenta is not accessible at the level of the internal 
orifice, it may be concluded that the detachment is not yet termi- 
nated. The management, then, varies according to the permea- 
bility of the internal orifice. 

When this orifice is supple and open, the indications are to wait, 
at the same time essaying uterine massage or expression, and, if 
after a certain time, the result is nul, to act as in the following case. 

If the internal orifice begins to close and if it is seen that longer 
waiting will prevent the introduction of the hand it becomes neces- 
sary to proceed to artificial delivery of the appendages. 

h. Partial retention. — There may be retention of a placental 
fragment, of an accessory cotyledon or of the membranes. When- 
ever the retention of a placental fragment or cotyledon is recognized 
the hand should be introduced into the uterus to effect its removal. 
If the cervix presents an impassible barrier, the indications are to 
wait and to watch the woman attentively, proceeding to curette the 
uterine cavity as soon as a fetid flow or septicaemic symptoms pre- 
sent. If only a section of the membranes is retained, simple ex- 
pectation is preferable to intervention. But if there is complete 
retention of the membranes immediate intervention is preferable. 

2. The hemorrhage exists alone (delivery of the appendages having 
been completed). 

To avoid repetition and discussion at length this subject may be 
presented in resume as follows : 

a. Hcemorrhages of medium intensity. — Three successive conditions 
to be determined : 

Uterine inertia ; ) 

Vulvar w^ound ; >■ Causes of haemorrhage. 

Vaginal or cervical wound ; ) 

Three therapeutic measures (outside of ligatures and sutures) : 
Hot antiseptic injections, 50° C. ; 
Ergot ; 

Utero-vaginal tampunnement. 

h. Grave and fulminant hcemorrhages. — A single condition is 
possible : 

Uterine inertia. 



388 Accidents of the Delivery of the Appendages. 

Three therapeutic measures : 

Compression and massage of the uterus through the abdominal 

wall. 
Introduction of a hand into the uterus. 
Utero-vaginal tamponnement. 

The gravity of the haemorrhages following delivery of the ap- 
pendages has aroused obstetricians to the creation of a series of 
measures which I consider inferior to those given above. I simply 
mention them, but advise that the three already described should 
have the preference. Among these procedures are, intra-uterine 
injection of the perchloride of iron, introduction into the uterus of a 
dilatable rubber bag, electricity, introduction of ice into the uterus, 
intra-uterine injections of alcohol, iodine or vinegar, and com- 
pression of the aorta through the abdominal wall or by the hand 
introduced into the uterus. 

3. The retention and tJie hcemor7'ha<je exist together. — The haemor- 
rhage will only cease with the expulsion of the appendages; to 
deliver the appendages is, then, the first indication. If the internal 
orifice is still open, artificial delivery will be easy, and, besides, 
permeability of the internal orifice is the rule, for the uterine inertia, 
the cause of the haemorrhage, allows gaping of the cervix. 

If the internal orifice is closed and does not allow the passage of 
the hand, a rubber bag will be introduced, which, by its dilatation, 
acts both by opening the cervix and as a plug to arrest haemorrhage. 
At the same time one hand exercises pressure on the uterus through 
the abdominal wall. At the end of one to two hours the dilatation 
will be sufficient to admit the hand and intra-uterine intervention 
will become possible. 



Accidents of Post-Partum, 389 



CHAPTER XXVII. 



ACCIDENTS OF POST-PARTUM. 

1. Hcemorrliages. — Post-partum actually commences at the 
moment when delivery of the appendages terminates, yet a haemor- 
rhage, which occurs a half- hour, an hour, or even more, after ex- 
pulsion of the appendages, is still considered as a haemorrhage of 
delivery, responding to the same causes and to the same treatment 
as those of this period of the puerperal state. Among the haemor- 
rhages of post-partum we only rank those which occur twelve hours 
after delivery. This is certainly an arbitrary limit, hut it responds 
quite well to the necessities of description. These haemorrhages 
are also designated as secondary, in distinction from those occurring 
during delivery of the appendages, which are primary. The post- 
partum lasts three months. We shall then study here the haemor- 
rhages occurring during this period consecutive to the birth of the 
child. 

These haemorrhages are of a variable abundance. They are 
sometimes slight, almost physiological, sometimes copious and 
capable of endangering the life of the patient. They may be ex- 
ternal or mixed, but the quantity of blood contained in the uterus 
can never be considerable as the organ at this time has returned 
upon itself. 

jEtiology. — a. Traumatic causes. — 

1. Exploratory traumatism, caused by the introduction of a sound 
into the uterus. 

2. Accidental reopening of a wound of the peiinaeum, of the 
yagina, or of the uterus. 

3. Too early resumption of sexual relations. 

4. Getting up too soon after delivery. 

h. Sj)ontaneous causes: 

1. Secondary inertia may be the cause of a haemorrnage.even as 
late as two or three days after delivery. 

2. Total and partial retention of the appendages. When an 
abundant haemorrhage occurs without apparent cause some days 
after accouchement, the possibility of this cause should always be 
remembered. 

3. Uterine deviation (especially retrodeviation) may also cause 
an obstinate haemorrhage. 



390 



Accidents of Post- Part um. 



4. UteTine inversion, unrecognized at the moment of delivery or 
produced later may also produce a persistent and abundant haemor- 
rhage. 

5. Ulceration. — Fibroma, cancer. 

6. Metritis. — Subinvolution. — Arrest of the normal involution, 
the frequent cause of metritis, produces repeated haemorrhages of 
slight abundance. 

7. Lactation. — At the moment when the child first takes the 
breast a slight haemorrhage is often noted, which is repeated at each 
nursing for some time. The explanation is found in the uterine 
contraction provoked by the irritation of the nipple. 




Fig. 464. — Different varieties of genital fistula?. 

The prognosis of these haemorrhages is in general benign, ex- 
ceptionally they become grave and demand an energetic treatment. 

The treatment will vary essentially according to the cause and 
the abundance of the flow. 

A slight haemorrhage usually ceases under the influence of repose, 
of hot vaginal injections, of the action of ergot or of digitalis. If 
there exist uterine deviation, metritis, or an inversion, the treatment 
appropriate to these various causes will be applied. 

A. haemorrhage of medium intensity will generally be subdued 1 7 
the same treatment. 

An abundant haemorrhage will be due, at the beginning of post- 
partum, to a secondary inertia and will require the same treatment 
as for inertia of delivery of the appendages. Later, it will be due 
to the existence of a fibroid or to the retention of placental debris. 
Such cases will require vaginal tamponnement with iodoform gauze 
or curetting of the uterus, followed by intra-uterine tamponnement^ 



The Vectis or The Lever. 391 

2. Fistid(E. — In consequence of a prolonged accouchement, when 
the foetal head remains in contact with the same point of the partu- 
rient canal for a prolonged period, or after a particularly difficult 
labor that has caused grave traumatisms, more or less extended 
necroses of the uterus, of the vagina or of the contiguous organs 
are seen. The eschars are cast off six to ten days after accouche- 
ment, establishing communications between the genital organs and 
the urinary passages or the intestine that are termed fistulae (Fig» 
464). These fistulse may also be produced during accouchement 
by perforation caused by instruments. 



CHAPTER XXVIII. 



THE VECTIS OR THE LEVER, 

he vectis was probably devised by Chamberlan at the same time 
as the forceps. It is composed of a handle terminated by a fenes- 
trated spoon (Fig. 465), recalling exactly a blade of the straight 
forceps. 




FlG. 465. — Ryerson's adjustable vectis. 

This instrument is passed into the genital canal and adapted to 
the occiput or to one of the parietal bones of the foetus. The handle 
is then grasped with both hands and given a lever movement, by 
which the foetal part is pushed toward the center of the parturient 
canal. 

Applied on the occiput, the lever produces flexion of the head ; on 
one of the parietal bones, lateral inclination, by depressing the pro- 
tuberance on which it acts. 

At present, the lever has been abandoned by all obstetricians as 
the forceps have the preference. It has the disadvantage of being 
only a correcting instrument (flexing the head or inclining it later- 
ally) and of not admitting traction as with the forceps. 



392 Versions. 

In the presence of this abandonment it is useless to insist at length 
on the action of this instrument. However, it ,may be again in 
favor some day, for if it has, in relation to the forceps, the dis- 
advantage of not permitting a prompt termination of the accouche- 
ment, it is capable of producing certain effects (flexion, lateral 
inclination) that the present forceps do not realize and that are 
valuable in a brow presentation, for example, or in a narrow pelvis. 
Bn ♦■. these are new points for future study and illumination. 



CHAPTER XXIX. 



VERSIONS. 

Version is an operation which has for its end a modification of 
the situation of the foetus in the uterus, in such a way as to change 
the presentation or to create one when it does not already exist. 
This modification in the foetal situation may be obtained in three 
ways: 

By external manoeuvres, external version. 

By internal manoeuvres, internal version. 

By mixed manoeuvres, mixed version. 

Independently of the manoeuvres executed, version is called : 
Cephalic, when the head is brought to the superior strait ; 
Pelvic or podalic, when the breech is brought down to de- 
termine the position. 

I. External version- 
Three stages are the same for each variety of version: 

1. To grasp the foetus. 

2. Foetal evolution. 
3*; Foetal fixation. 

1. Grasping the foetus (Fig. 466). — After determining the exact 
situation of the foetus, a hand is applied on each of the poles of the 
child, so as to grasp it firmly. When the two extremities are thus 
held, it can be given the desired movement. 

2. Foetal evolution (Fig. 467). — The two poles being grasped as 
indicated, the hands exert a soft and progressive pressure in con- 
trary directions, so that the breech may be directed toward the 
fundus of the uterus and the head brought to the superior strait by 
the shortest road. However, if difficulties are found in causing the 



Versions. 



393 



cephalic extremity to descend in one direction, the opposite course 
may be taken in the direction of least resistance. During their 
displacement the hands glide on the skin, which may be smeared 
with vaseline, if necessary. 



^^ — i^ 




Fig. 466. — First stage. Grasping the foetus. 

3. Foetal fixation. — When the head has been brought to the 
superior strait, it is necessary to fix it in this new position, to 
avoid return of the vicious presentation. For this purpose I use a 
belt furnished with four distinct cushions (Fig. 468). These pads, 
which can be inflated separately, permit it to act directly on the 
breech and on the head ; they constitute four boundaries fixing the 
extremities laterally and maintaining the child in the desired 
position. 

II. Mixed version. 

a. Podalic version. 

1. Grasping the foetus (Fig. 470). — The abdominal hand grasps and 
depresses the breech while the vaginal hand pushes up the head of 
the child ; from this double action results foetal evolution. The ac- 
coucheur being placed on the right side of the woman applies the 



894 



Versions, 



left hand on the breech which is graLsped as in external version, 
wliile one or several fingers of the right hand are introduced into 
the vagina to seek the foetal part. 




FfG. 467. — Second stage. Foetal evolution. 

1. Foetal evolution (Fig. 471). — The abdominal hand depresses the 
breech, while the vaginal hand pushes up the different foetal parts as 
they successively present at the uterine orifice. The foetal evo- 
lution should be made as much as possible on its anterior or sternal 




Fig. 468. — (Third stage, Fcetai fixation). Entocie belt, with four 
lateral dilatable cushions. 

plane, for in this way the pelvic members arrive at the uterine 
opening more easily, where their seizure abridges the operation. 



Versions. 



395 



/"./T"*"-,^ 



/ 




Fig. 469. — Mobilization of the engaged foetal part. 

3. Foetal fixation (Fig. 472). — As soon as one of the small pelvic 
members becomes accessible, it is grasped through the uterire 
orifice by one or two fingers and brought down into the vaginal 
cavity. 

h. Cephalic version (Fig. 473). — The hands are placed in a similar 
manner. The evolution is made in the opposite direction to that 
of podalic version, that is, by depressing the head and pushing up 
the breech first, and then the different foetal parts successively, as 
they become accessible. Fixation is made, as in cephalic version, 
by external manoeuvres. 



III. Internal version. 

1. Seizure of one or more foetal parts. — The aim will be to grasp one 
or both feet of the child and bring them to the vulva. This com- 
prehends a series of secondary questions which will be touched 
upon successively as follows : 

The hand to be introduced ; 

The mode of introducing the hand ; 



396 



Versions. 




'^ 4 



Fig. 470. — External podalic version. First stage (Braxton Hicks). 




Fig. 471. — External podalic version. Second stage (Braxton Hicks). 



Versions. 



397 




Fig. 472.— External podalic version. Third stage (Braxton Hicks). 




Fig, 473.— External cephalic version. 



398 



Versions, 








Fig. 474. — Internal podalic version. Grasping the feet in thorax 
presentation (dorso-anterior). 




Fig. 475. — Internal podalic version. Grasping the feet in thorax, 
presentation (dorso-posterior). 



Versions, 



399 



The search for the feet ; 

The seizure of the feet. 

The hand to he introduced. — I always introduce the right hand 
first, and if, by hazard, I fail to grasp the feet, it is withdrawn and 
the left replaces it. I prefer, in the exceptional cases in which it 
becomes necessary, to preform this double manoeuvre, which is 
without inconvenience to the anaesthetized woman, rather than to 
torture the memory with a series of principles for the most part 
useless. 




Fig. 476. — Internal podalic version. Grasping the feet in vertex presentation. 

The mode of introducing the hand.— The hand, smeared with vase- 
line over all its dorsal region, takes the form of a cone. With this 
configuration favorable to penetration, the hand is passed thiough 
the vagina to the cervix. The cervix should be sufficiently dilated 
to allow the hand to pass (a requisite condition for internal version) ; 
complete dilatation is only indispensable for extraction. Arrived 
at the cervix the hand meets the bag of waters when it is yet intact ; 
this must be ruptured before penetrating into the uterus. 

The search for the feet.— ^Nhsii direction should the hand follow to 
arrive most easily at the feet of the child ? The pelvic members 



400 



Versions. 



being, save very rare exceptions, flexed and folded along the 
anterior plane of the foetus, it is by following this sterno-umbilical 
plane that they are most easily found (Figs. 474, 475, 476, 477). 

The seizure of the feet. — If the two feet are easily found, they are 
grasped and drawn down to cause evolution of the foetus ; but in 
case only one foot can be found, it is useless to delay to seek a second, 
for the single foot is perfectly sufficient to execute version. 




Fig. 477. — Internal podalic version. Second stage. Foetal evolution. 

2. Foetal evolution. — For evolution it is necessary to exert traction 
on the foot or feet grasped, to draw the parts outward. At first 
there will be felt a certain resistance, then if evolution is possible 
the foot or feet descend, drawing down the breech, and thus pro- 
ducing evolution. 

The tractions for evolution as well as the progression of the hand, 
in the first stage, should only proceed during the intervals of the 
uterine contractions. 

The hand, which during the first stage was placed on the fundus of 
the uterus to maintain it, should aid evolution, either by supporting 
the breech or by pushing the head toward the fundus of the uterus. 

3. Foetal fixation. — This third stage is without importance here, 



Versions. 401 

for, if the dilatation is complete, version is generally terminated by 
extraction; if not, it is sufficient to leave the foot or feet in the 
vagina or at the vulva. 

Prognosis. — The prognosis of the different versions, for the mother 
and for the child, depends upon : 

The operator ; 

The variety of the version employed ; 

The circumstance proper to each particular case. 

The operator should be experienced and aseptic. 

In a general manner the gravity of each variety of version be- 
comes less as there is less penetration into the genital organs. 
Internal version is the most serious and external the most benign. 

With regard to the different circumstances which may cause 
variations in the prognosis, they are too numerous to mention. 
Complications and difficulties may arise that will produce a very 
grave prognosis. 

However, we may say that when properly performed and executed 
at the correct moment, these different versions usually permit us 
to save the mother and the child, and that they constitute one of 
the most valuable resources of obstetrics. 



i02 



Forceps, 



CHAPTER XXX. 



FORCEPS. 

The forceps is a sort of pincers with separable blades used to 
grasp the foetus and extract it from the genital canal. There are 
many varieties of forceps, but we may separate them into three 
classes. 




Fig. 480 — Unicurved forceps. XVIIth century (Chamberlan). 

1. The unicurved forceps. — The first forceps, devised by Cham- 
berlan (Fig. 480), possessed a single curve, the cephalic curve, and 
was thus a unicurved forceps. Like all the instruments of the 
present day it is composed of two branches, each divided into a 
handle, a blade, and an intermediate part, or articulation. The two 
halves of the instrument are called the right and left blades, and 
also the male and female blades ; the left branch, or male blade, 
bearing the pivot of the articulation. These denominations should 
be remembered as they will be constantly met in the descriptions 
which follow. 




Fig. 481. — Simpson's forceps. 

2. The bicurved forceps. — The priority of this modification belongs 
to Levret (Fig. 482), who, in 1747, published a description of a 
forceps with two curves, one cephalic, the other pelvic, seen on ex- 
amining the instrument in detail. The various bicurved forceps of 
the present day are designed, like those of Levret, with one curve, 
adapted to the head, the other to the pelvis. 



Forceps. 



403 



3. The tricurved forceps, — The most complete forceps of this class 
^as that produced by Tarnier, in 1877. In a general way it resembles 
that of Levret, but differs in three principal points (Figs. 483 and 
484): 

1. By the presence of a pressure screw, placed at the side of the 
articulation, to supplement the action of the hands in keeping the 
handles together; 

2. By the addition of two movable rods, destined to transmit the 
traction ; 

3. By a traction handle fitted to the preceeding, and designing 
ihe perinaeal curve. 




Fig. 482. — Bicurved forceps (Levret). 

From this disposition, the tricurved forceps presents the follow- 
ing advantages : 

1. It. permits traction in the axis of the genital canal. 




Fig. 483. — Tarnier's axis-traction forceps. 

2. It allows the head its mobility, since the tractions are made 
by an apparatus articulating with the blades which are thus left to 
themselves, after fixation with the pressure screw. 



404 



Forceps, 



3. It possesses an indicating needle, constituted by the handles, 
which, by showing the movements of the still invisible head, is 
valuable in pointing out the direction in which the tractions should 
be exercised. 




Fig. 484. — Tricurved forceps. 

The different types of forceps, so far studied, are those with 
crossed branches, but there is also another variety with parallel 
branches. Like the first variety we have described, forceps with 
parallel branches may be divided into three principal types : the 
uni curved (Fig. 485), the bicurved (Fig. 486) and the tricurved (Fig, 
487). For mechanical reasons forceps with parallel branches do 
not exert as great a compression on the foetal part between the 
blades as the crossed forceps, yet their employment is not common 
at present, and I leave them out of consideration, together with a 
series of various models, which only realize ingenious ideas. 

Application of the forceps. 

It is indispensable to divide this study into two parts : 
a. The general application of the forceps. 
h. The particular applications. 

a. General application, — There are three successive stages : 

1. Introduction. 

2. Articulation. 

3. Extraction. 

First stage. — There are three rules relating to the introduction 
of the forceps, the first concerning the mother, the second the child, 
and the third the forceps. 



Forceps, 



405 



1. Maternal rule. 

Eight branch, grasped with the right hand, introduced to the right 
of the woman. 

Left branch, grasped with the left hand, introduced to left of the 
woman. 




Fig. 485. 



Fig. 486. 



Porallel unicurved forceps Parallel bicurved forceps 
(Thenance, 1781). (Valette, 1857). 



Fig. 487. 

Parallel tricurved forceps 
(Poullet). 



2. Foetal rule. 

The child should be grasped from one ear to the other. If there 
is a presentation of the cephalic ovoid the diameter grasped should 
be : 

The biparietal for the vertex ; 
The bimalar for the face ; 
The bitemporal for the brow. 

In cases of breech presentation the bitrochanteric diameter will 
be chosen. 



406 



Forceps, 



3. Instrumental rule. 

The left branch is always to be applied first, thus avoiding cross- 
ing the handles in articulating. 




Fig. 488.— Introduction of the left blade. 





J ,f H-.. /J 



Fig. 489. — Left blade introduced. 



Forceps. 



407 



Such are the rules for the introduction of the forceps. Let us 
now put them into execution by taking, as an example, the most 
simple case, a vertex presentation in the occipito-pubic position, 
the head at the vulva. 




Fig. 490. — Introduction of the right blade. 

Introduction of the left branch (Figs. 488, 489). — The left blade is 
held in the left hand as indicated in Fig. 488. Two fingers of the 
right hand are introduced at the lateral and inferior part of the vulva. 
(When the head is higher up it is better to introduce four fingers 
to seek the cervix and thus to avoid perforation of the culs-de-sac 
with the blades.) The instrument is made to penetrate backward 
and laterly, and brought gently to the side of the head in the position 
it should occupy definitely (Fig. 489). 

Introduction of the right branch (Figs. 490, 491). — The right branch 
is held in the right hand, the left hand serving to guide the ])lade, 
and introduced into the genital organs above the branch already 
placed. 



408 



Forceps. 




Fig. 491. — Right blade introduced. 




Fig. 492. — Articulation- Locking. 

Second stage. — To proceed to articulation, that is to say, to lock- 
ing of the two blades (Fig. 492), each handle is grasped and after 
crossing, if necessary, parallelism of the branches is established. 



Foxceps, 



409 



The pivot of the male branch is made to penetrate into the mortise 
of the female branch and the blades are made secure by tightening 
the screw (Fig. 493). 




Fig. 493. — Articulation. Application of the screw (the handles at this moment 
should be horizontal. In Figs. 492, 493 they are inclined backward to show the de- 
tails of the operation. 

After articulation of the forceps, before proceeding to extraction, 
examination is made to be sure that the head is well grasped and 
grasped alone. If a loop of the cord or other part is included 
between the blade and the foetal part, the forceps must be removed, 
or at least the part badly applied, for reintroduction. The forceps 
should be removed in the following manner. After unlocking, the 
right branch is retired by making it folloAv gently a passage ab- 
solutely the inverse of that of introduction, then the left branch is 
withdrawn in the same way. 

Third stage. — Supposing the forceps to be properly applied we 
may proceed with extraction. The forceps is grasped with both 
hands (Fig. 494), the left below, the right above and nearer the 
vulva, so as to give the instrument a lever movement, indispensable 
for traction in the axis. 

At the moment when the head opens the vulva, the forceps is held 
with one hand (Fig. 495), progressively elevating the handle so as 



410 



Forceps, 



to give a movement of extention to the cephalic extremity. The 
thumb of the other hand is applied on the perinseum, supporting 
the foetal head and moderating the rapidity of the exit, so as to avoid 
laceration. 




Fig. 494. — Extraction. Arrival of the head at the vulvar orifice. 




Fig. 495. — Extraction. The head opens the vulvar orifice. 



Forceps, 



411 



h. Particular applications. — llhe forceps may be applied on the 
vertex, the face, the brow, the breech, or the head last. 



\ "> 




O.y/' y 




Fig. 496. — Rotation of the blades upon Fig. 497 — Rotation of the blades upon 
the axis of the handle (bicurved forceps), their axis (tricurved forceps). 

I. Vertex, 

When the foetal part arrives in the soft pelvis it may still be 
found in the excavation or at the superior strait. 

1. Soft pelvis (from the median strait to the vuiva). — Direct appli- 
cation. The vertex on arriving at this region is generally placed 
in P, exceptionally in S. 

P. — This is the easiest application of the forceps, that which we 
have taken as a type and already described. 

S. — The forceps is placed as on a head in P, and extraction 
may be made in two ways, either in occipito-sacral or in occipito- 
pubic, by giving the head a movement of rotation designed to bring 
the occiput forward. 

When rotation can be made it is preferable. This movement 
should be made by causing the handles to describe the arc of a 



412 



Forceps. 



circle (Fig. 497). Eotation of the blades in the arc of a circle (Fig. 
496) must be avoided on account of the injury it would cause to the 
maternal parts. 

2. Excavation. — Oblique application. — The sagital suture is placed 
in relation to one of the oblique diameters. 

L I A. — Lett blade to the left and backward. Eight blade, in- 
troduced to right and backward, then brought forward and to the 
right by a spiral movement (Fig. 498). 




Fig. 498. — Spiral movement. 

L I P. — Left blade, to the left and forward. Eight blade, to 
the right and backward. Movement of rotation to bring the occiput 
forward by the shortest way. After this movement of rotation the 
forceps is found placed in the opposite direction and if extraction 
cannot be terminated they must be removed and reapplied. In 
case rotation is impossible, extraction in S is made. 

E I A. — Left blade, to the left and forward. Eight blade, to the 
right and backward, the occiput is brought forward and extracted. 

E I P. — Left blade, to the left and backward. Eight blade, to 
the right and forward. Movement of rotation to bring the occiput 
forward for extraction in P. If rotation is impossible, extraction 
in OS. 

3. Superior strait. — Transverse application. Three ways of seizing 
the head present : 

Biparietal ; 
Occipito-facial ; 
Parieto-frontal. 

The biparietal method of grasping the head, while the best in 
theoretical point of view, presents in practice serious disadvantages, 
its relative difficulty, the increase in diameter by the application of 



Forceps, 41S 

the blades, and the prevention of the oscillation of this diameter 
during descent through a contracted superior strait. Thus the two 
other methods of seizure are preferable. As a rule the occipito- 
facial should be used, and in case it fails the parieto-facial method 
should be attempted, the biparietal seizure being reserved for 
relatively rare cases and for a special form of pelvis. 

L I T. — The left blade to the occiput, the right on the face. 
The head is made to descend into the excavation in the transverse 
position; it is placed in P at the median strait, and from this 
moment, according to the suppleness of the soft tissues, the ex- 
traction is terminated by leaving the forceps in position or by 
reapplying the blades to grasp the biparietal diameter. 

E I T. — Left blade on the face ; right blade on the occiput. The 
head is made to descend into the excavation in the transverse 
position. The occiput is then brought forward and extraction 
terminated as in L I T. 

II. Face, 

1. Soft pelvis, — Direct application. 

M P. — Same application as in P. Extraction conforming to 
the normal mechanism. 

M S. — Same application as for M P. In extraction the chin must 
be brought forward. 

2. Excavation, — Oblique application. All that has been said 
apropos of vertex presentation applies here, with the difference that 
it is always necessary to bring the chin forward. 

3. Sujjerior strait, — Transverse application. When the head in 
face presentations is still at the level of the superior strait, it is 
much better to use podahc version, or reduction of the face into 
vertex, follow^ed by application of the forceps, if necessary. 

How^ever, if in these conditions it is desired to apply the forceps, 
it will be preferable to apply the blade of the forceps on the bi- 
malar diameter ; but this intervention is not to be advised. 

III. Broiv. 

1. Soft pelvis, — Direct application. The forceps may be applied 
from one ear to the other and the head extracted directly by imi- 
tating the mechanism of a normal exit as much as possible. 

2. Excavation. — Oblique application. Apply the forceps as in an 
analogous presentation of the vertex, after having attempted trans- 
formation into a vertex. 

3. Superior strait. — Transverse application. Attempt transfor- 
mation into vertex or internal podaiic version, if the conditions are 
favorable; if not, apply the forceps as if in presentation of the 
vertex and make extraction by bringing the occiput forward. 



414 



Forceps, 



IV. Breech. 

The forceps will only be indicated in presentation of the breech, 
variety of the buttocks ; in all other cases the feet will be seized 
and manual extraction performed by preference. 

To apply the forceps on the breech, grasp the bitrochanteric 
diameter and perform extraction by imitating the normal mechan- 
ism of accouchement. 

V. Head last. 

The after-coming head may be retained : 

By the bony pelvis ; 

By the cervico-uterine segment; 

By the soft pelvis. 

In the first case the forceps is a bad method of extraction ; the 
hand is preferable. 

In the second case, the forceps is relatively better, but manual 
extraction is more certain. 



« / '■F>x. - 



/ 




Fig. 499. — Extraction with the tricurved forceps. Arrival of the head 
at the vulvar orifice. 

In the third case, where the hands are insufficient the forceps i& 
a valuable resource of extraction. To apply the instrument in 
such a case, it is sufficient, after having brought the occiput for- 
ward, to have the child's body uplifted by an assistant and to glide 
each one of the blades on to the lateral parts of the cephalic ex- 
tremity, as in head first. Disengagement is performed by giving 
the foetal part a hinge movement around the lower part of the 
symphysis pubis, the occipito-cervical groove remaining in contact 
with the maternal pubis. 

2. Tricurved forceps. — The introduction of the blades is made ac- 
cording to the same principles as for the bicurved forceps. 



Forceps. 



415 



Articulation should be completed by the fixation of the pressure 
screw and adaptation of the traction handle and rods. 

Extraction takes place simply by grasping the traction apparatus, 
leaving free the forceps handles as an indicator. It is necessary 
to exercise traction (Fig. 499) in such a way that between the 
handles of prehension and the traction handle there will be an 
interval vi about a finger's breadth. 




Fig. 500. — Extraction with the tricurved forceps. The head opens 
the vulvar orifice. 

At the moment when the head opens the vulva, the forceps are 
grasped with the left hand (Fig. 500) while the right supports the 
perinaeum. 

To accomplish rotation with the axis traction-forceps, one hand 
should hold the traction apparatus while the other gives a turning 
movement to the handles, causing them to describe a rotation 
around the traction rods as a center. 



416 Manual Extraction, 



CHAPTER XXXI. 



MANUAL EXTRACTION. 

When the foetus presents by the breech the obstetrician may, by 
grasping the pelvic members with the hand, practice extraction in 
the same way as with the forceps in a presentation of the cephaHc 
ovoid. Thus, besides extraction by the forceps, there exists manual 
extraction, which must not be confounded with podalic version. 

In preparing for manual extraction the patient should be placed 
in the obstetrical position as for the forceps and internal version. 
Anaesthesia is used or not according to the woman and to the 
assistants at disposal. 

The operation is performed in three stages : 

1. Grasping the feet. 

2. Extraction of the trunk. 

3. Extraction of the head. 

FiKST STAGE. — The right hand is introduced into the genital 
organs to grasp, according to the facility, one foot alone or both 
feet. If extraction succeeds to internal version, this first stage is 
found already executed. 

Second stage. — During the whole of the extraction an assistant 
supports the fundus of the uterus and compresses it with both hands. 

Lower limhs (Fig. 506). — The limbs are grasped with both hands 
and drawn strongly downward in the supposed direction of the axis 
of the superior strait. 

Breech (Fig. 507). — As soon as the breech appears at the vulva, 
it is grasped with both hands, covering it with a cloth, at need, to 
prevent slipping. The tractions are continued. 

Abdomen (Fig. 508). — The abdomen is disengaged without re- 
moving the hands from the breech. It should never be grasped 
with the hand on account of the lesions that might be thus produced. 
As soon as the cord becomes visible, its placental extremity should 
be drawn out to constitute a looj) that will avoid the dragging to 
which it will be exposed without this precaution. 

Thorax, — The tractions on the breech are continued, directing the 
vertebral column toward the middle of the ischio-pubic ramus in 
Such a manner that the head on arriving in the excavation is placed 
easily and naturally in the P. 

Third stage. — When the head is small, well flexed, the genital 
passage large and supple, and when the abdominal expression has 



Manual Extraction, 



4X1 




Fig. 506. — Grasping the inferior members. 




Fig. 507. — Grasping the breech. 



418 



Manual Extraction. 



been well made, it sometimes happens that the cephalic ovoid, after 
the expulsion of the shoulders, makes a sudden exit from the genital 
organs, as if ejaculated. 




Fig. 508. — Liberation of the cord. 




Fig. 509. — Manual extraction, exit of the head. 

But usually it becomes necessary to assist its exit by introducing 
one or two fingers in the child's mouth, placing the other hand on 
the neck (Fig. 509). The tractions made by the two hands thus 



Manual Extraction. 



419 



placed should flex the head and give it a hinge movement around 
the occipito- cervical groove placed under the maternal pubes. 




Fig. 510. — Manual extraction, drawing down the posterior arm. 

There may also be difficulties in extraction caused by uplifted 
arms. In this complication, drawing on the child in the hope of 
seeing the head and arms expelled simultaneously must be guarded 
against. If this is done, extraction wiU become impossible except 
with a relatively small child. It is necessary to draw the arms 
down successively, in a different manner, according as the head has 
arrived at the median strait or is stiU retained at the superior strait. 




Fig. 511. — Manual extraction, drawing down the anterior arm. 

1. Head at the median strait. — Commence by disengagement of 
the posterior arm (Fig. 510). After strongly uplifting the child the 
fingers are introduced into the vagina to grasp the arm. Placing 
the fingers parallel to the humerus the arm is drawn down by 
making it follow the inverse movement of raising it up (Fig. 511). 



420 Induced Expidsion. 

2. Head at the superior strait. — When the head is retained at the 
superior strait, by a contracted pelvis for example, it is necessary 
to proceed to the same successive disengagement of each arm, but 
here, in place of beginning with the posterior shoulder, it is better 
to extract the anterior first, for it is only separated from the hand 
by the height of the pubes, while the posterior shoulder being found 
at the promontory it would be necessary to follow the perinseum^ 
the coccyx and the sacrum. 



CHAPTER XXXII. 



INDUCED EXPULSION. 

Premature expulsion should be performed : 

1. When there is a disproportion between the parturient canal 
and the foetus. Causes : Pelvic deformity, excess of volume of the 
foetus, or both combined. 

2. AVhen there are indications, other than these, furnished by the 
mother or by the foetus. 

Mother — 

Any grave condition capable of being modified for the better by 
the interruption of pregnancy becomes an indication for induced 
expulsion. Such are : 

Incoercible vomiting. 
Grave or pernicious anaemia. 

Any grave disease of the lungs (asphyxia), of the heart (asystole), 
or of the kidneys, menacing the existence of the woman and capable 
of being reheved by the expulsion of the ovum.. 

Foetus. — 

The foetal indication is furnished by that pathological state which 
we have studied under the term habitual death. In such cases we 
are authorized to induce premature labor to save the child. This 
indication disappears if the death precedes the last three months 
of pregnancy. 

Contraindications. — The contraindications are three in number. 

1. The death of the foetus. 

2. The grave condition of the mother, capable of fatal termination 
under induced expulsion. If the operation is to save the child. 



Induced Expidsion, 421 

being given the imminent death of the mother, it is better to wait 
a favorable moment for Caesarian section. 

3. The formal will of the mother, who, in full possession of her 
faculties, desires to save the child by going to term and submitting 
to a Caesarian section. 

The different methods which have been proposed for the in- 
duction of premature expulsion may be classed in the following 
manner : 

I. Indirect methods. — 

f I. Ancient authorities, rue, yeu, sabina. 
1. Internal J ^' ^ongiovanni, ergot. 

} 3. Sayre, sulphate of quinine. 



2. External. 



l^ 4. Mari-Autet, pilocarpine hydrochlorate. 

1. D'outrepont, uterine frictions, massage. 

2. Schreiber, Simpson, faradization. 

3. Gardien, repeated hot baths. 

4. Friedreich, Scanzoni, suiapisms, cups to the breasts. 



II. Direct methods. — 

{I. Schoeller, vaginal tampon. 
2. Huter, Braun, colpeurynter. 
3. Kiwish, douches to the cervix. 

{I. Kluge, prepared sponge. 
2. Van Leynseele, laminaria. 
3. Barnes, Chassagny, rubber SaC. 

3. In the uterus: 

f I. Krause, elastic sound. 
a. Non-dilatable body. \ ^' Schweighauser, utero-ovuline injection. 

^ I 3. Hamilton, detachment of the membranes with 
[ the finger. 

{I . Tarnier, rubber bag. 
2. Pajot, Tarnier's dilator modified. 
3. Champetier de Ribes, inextensible bag. 

{I. Scheel, trocar (perforation of the membranes at the cervix). 
2. Meissner, trocar (perforation of the membranes at a point 
distant from the cervix). 

x\mong these numerous methods, the three best procedures for 
inducing premature expulsion of the ovum are, the perforation of 
the membranes and the introduction into the uterus of a dilatable 
or a non-dilatable body. 

Perforation of the membrane has the disadvantage of depriving 
the foetus of a part of its amniotic liquid and thus of exposing in a 
greater degree to the dangers of accouchement. Therefore, unless 
it relates to abortion, where the life of the child is indifferent, it is 
better to give the preference to one of the two methods which follow : 

The introduction of a dilatable body is happily realized by 
Tarnier's rubber bag, carried into the uterus by the aid of a special 
instrument ; but this apparatus is quite complicated, the bag some- 
times bursts, an accident necessitating the introduction of a new 
dilator. Kibes has recently advised a dilator of inextensible tissue, 



122 



Induced Expulsion, 



that is, dilatable only to a certain extent ; this dilator has the ad- 
vantage of promptly inducing labor and of causing a rapid opening 
of the cer\dx, but the relative difficulty of its introduction, into the 
uterus, the dangers of the vicious presentations to which it exposes 
and, finally, the frequent procidence of the cord as a consequence 
of its introduction, will prevent its coming into common use. 




Fig. 512.— Sound introduced into the uterus and folded in the vagina 
(Krause's procedure). 

Introduction of a non-dilatahle body. — The most simple and the best 
procedure is that advised by Krause, which consists of introducing 
a simple sound or elastic bougie into the uterus (Fig. 512). The two 
accidents that may be observed during the introduction of the in- 
strument are, perforation of the membrane and a haemorrhage 
proceding from a traumatic detachment of the placenta. 

The first is a simple annoyance ; the second may be left or be 
withdrawn, as expulsion will be induced by the perforation of the 
membranes. The haemorrhage resulting from a placental detach- 
ment is a more serious complication ; it is necessary to withdraw 
the instrument and to attempt its introduction in a new direction. 
If the flow of blood continues or takes serious proportions it may 
become necessary to apply the treatment advised for placenta 
praevia. 

The bougie demands watching, for under the influence of uterine 
contractions it is sometimes expelled into the vagina and needs to 
be introduced again. 



Embryotomy. 423 



CHAPTER XXXIII. 



EMBRYOTOMY. 

When the fcetus is too voluminous to pass through the parturient 
canal it becomes necessary, unless we resort to Caesarian section, 
to extract it by reducing it at the sacrifice of its existence. This 
operation is called embryotomy. 

According as the foetus presents by the head or by the trunk, the 
reduction will relate to one or the other part ; we have, then, two 
varieties of embryotomy : 

Cephalic embryotomy, reduction of the head. 

Cormic embryotomy, reduction of the trunk. 

The trunk, like the head, is composed of viscera enclosed in a 
more or less resisting wall. Now, embryotomy is sometimes ad- 
dressed to one, sometimes to both, of these two elements — viscera 
and wall. In this point of view there are also two varieties of 
embryotomy : 

Visceral embryotomy. 
Parietal embryotomy. 

Visceral embryotomy consists, for the cephalic ovoid, in the 
evacuation, after perforation of the cranium, of the cerebral sub- 
stance, and for the cormic ovoid, in tearing away the viscera oc- 
cupying the thoracic and abdominal cavities after perforation. In 
both cases it is an evisceration differing only by the organs to which 
it relates. 

Parietal embryotomy for both ovoids, consists in reduction of the 
size in four different w^ays : 

By compression — wiiich is exerted on the eviscerated ovoid by the 
forceps or by an analogous instrument. 

By accommodation — when, for example, with the aid of the crani- 
oclast, a perforated head is drawn slowly, or when, after the section 
of the neck, each ovoid is extracted slowly by accommodating it to 
the genital passage. 

By crushing — if the bones are broken, to lessen the resistance 
opposing the passage of the child. 

Finally, by morcellement — when the body of the foetus is extracted 
piece by piece. 

These different modes of reduction are often combined under the 
action of one apparatus. 

Numerous instruments have been proposed for the execution of 



424 



Embryotomy, 



these manoeuvers, but at the present day those most in use are the 
cephalotribe, the cranioclast and the scissors. 

Let us study successively the cephalic and the cormic embry- 
otomies. 

I. Cephalic embryotomy. — Cephalic embryotomy is composed, as 
has been indicated, of two successive operations : eviseration, which 
necessitates perforation of the cranium, and reduction. 

Among the numerous visceral embryotomies or perforators that 
devised by Blot is the best (Fig. 513). 




Fig. 513. — Blot's perforator. 



Fig. 514. — Lusk's cephalotribe. 



The cephalic embryotomies par excellence are the cranial forceps, 
of which there are three varieties : The intra-cranial forceps, in 
which the two jaws, introduced through the perforation, grasp the 
base of the cranium. The extra-cranial forceps, or the cephalo- 
tribe (Fig. 514), in which the two jaws are applied to the periphery 
of the skull. The mixed variety of forceps, or the cranioclast (Fig. 



Embryotomy. 



425 



515 and 516), in which one extremity is applied in the cranium the 
other on the periphery. 

The intra-cranial forceps is but little used. 





Fig. 515. — Braun's cratiioclast. 



Fig. 516. — Simpson's cranioclast. 



The cranioclast, however, has an extended employment in various 
models. The plain or the male blade is introduced into the cranium 
through a perforation i^reviously made and the fenestrated branch, 
or female blade, is applied on the periphery, preferably on the face. 

The cephalotribe is only a strong forceps furnished with a pressure 
screw for crushing. One of the best models is that of M. Bailly 
(Fig. 517). After the perforation of the cranium it is applied like 
the forceps and the head is crushed to the extent necessary to 
permit extraction. 

In 1884 Tarnier modified this instrument, giving it the name of 



426 



Embryotomy, 



basiotribe (Fig. 518). Later, Bar perfected it by some modifi- 
cations (Fig. 519). The basiotribe is composed of a central branch 
which serves as a perforator and of two lateral branches recalling 
those of the cephalotribe. The operation is commenced by the 
introduction of the perforating branch and then the two lateral 
blades are placed and the crushing is successively executed with 
each one of them. 




Fig. 517. — Bailly's cephalotribe. 

Combined forceps. — Combined cephalic embryotomy. — The cephalo- 
tribe constitutes an excellent crushing instrument. On the other 
hand, the cranioclast has no rival so far as solidity is concerned. 
These two instruments are then indispensable to the accoucheur. 
But by adding a third branch to the cephalotribe I have designed an 
instrument which may be employed as a cranioclast at need, and 
which by the addition of this third branch affords all the services 
of the cephalotribe or of the basiotribe. To practice cephalic 
embryotomy with this instrument we proceed as follows : The 
woman being anaesthetized and placed in the obstetrical position, 
an assistant is instructed to maintain the head firmly by placing 



Embryotomy, 



427 



one hand on each side of the hypogastrium. Guiding it on the left 
hand, the perforator is introduced and by a gimlet it is sunk into 
the most accessible part of the cephalic ovoid. When this branch 
has penetrated the cranium it is pushed in different directions to 
dissociate the cerebral substance. The point of the instrument is 




Fig. 518. — Tarnier's basiotribe. 



Fig. 519. — Bar's cephalotribe. 



directed as much as possible toward the occipital foramen. An 
assistant is charged with maintaining this branch supported on the 
base of the skull; the curve of the instrument (marked on the 
handle) is turned toward the left side, that is, toward the blade that 
is next applied. The left branch is then introduced and applied 
iike the blade of the forceps on the foetal head. When this is ac- 
complished, the branch will be maintained by a hook at the handle. 
Thus applied (Figs. 523, 524, 525) the combined cephalic embryotome 
is only an ordinary cranioclast and can be employed as such if its 
action is judged sufficient. But if it is deemed necessary to com- 
plete the crushing, the right blade is applied like the right blade of 
the forceps and articulated. Then crushing can be performed by the 



428 



Embryotomy. 



use of the screw. As soon as this is completed the right branch, 
like the left branch, as we have already seen, is held by a hook (Fig. 
526) so that the pressure screw can be removed and extraction per- 
formed. 




Fig. 520. — Combined 
cephalic embryotome. 



Fig. 521. — Perforation 
of the cranium. 



Fig. 522. — Application of 
the left blade. 



II. Cormic embryotomy. — As for the cephalic ovoid, we are here in 
the presence of two distinct operations, evisceration and reduction. 

For cormic embryotomy there are numerous instruments, but 
among these Dubois' scissors (Fig. 527) is sufficient to perform all 
the varieties of cormic embryotomy, and on this subject I shall be 
confined to indicating their em^Dloyment in : 

1. Evisceration. 

2. Decollation. 

3. Eachitomy. 

4. Melotomy. 

5. Morcellement. 

1. Evisceration {presentation of the ahdomen). — The left hand being 
introduced as far as the foetal part which presents, by the use of 



Embryotomy. 



429 



the scissors guided on this hand the abdominal wall is opened and 
through this opening, enlarged by the ringers, the abdominal and 
thoracic organs are torn out so as to empty these cavities of their 
contents. This evacuation generally permits termination of the 
extraction by internal podalic version without difficulty. 




Fig. 523. — First crushing. 



Fig. 524. — Application 
of the right blade. 



Fig. 525. — Second crushing. 
Instrument applied. 




Fig. 526. — Braun's decapitating hook. 



430 



Emhryotoniy. 



2. Decollation (presentation of the thorax). — The foetus presenting 
by the thorax and version becoming impossible, it is necessary in 
order to terminate the accouchement to decapitate the foetus, so as 
to extract successively the trunk and then the head. For this 




Fig. 527. — Dubois' scisors (modified by Pinard). 




Fig. 528. — Section of the neck, with Dubois' scisors. 

section a hand, preferably the left, is introduced to grasp the neck 
and draw it down as much as possible. The neck being thus held, 
the scissors are used with the free hand and the head severed by 
small cuts (Fig. 528). As soon as the section is completed, and 



Embryotomy. 



431 



care has been taken to tear loose the remaimng soft parts, one of 
the arms is seized and the cormic ovoid extracted (Fig. 529). To 




Fig. 529.— Extraction of the cormic ovoid. 








Fig. 530.— Extraction of the cephalic ovoid. 



432 Hysterotomy. — C cesarean Section. 

extract the head, which remains alone in the genital organs, a 
finger is hooked on to the inferior maxillary through the mouth and 
this generally serves for extraction (Fig. 530) ; if not, the forceps 
are used, or even, if reduction is necessary, the cephalic embry- 
otome. 

3. Rachitomy. — If section of the spinal column is necessary it is 
accomplished by the scissors guided by a hand introduced into the 
genital organs. 

4. Melotomy. — Section of the limbs, when necessary, may also be 
made with Dubois' scissors guided to the parts to be divided by a 
hand in the genital passage. 

5. Morcellement consists in extracting the foetus in fragments/ 
Dubois' scissors will permit this detachment in portions. 



CHAPTER XXXIV. 



HYSTEROTOMY.-CiESARIAN SECTION. 

Hysterotomy, or the Caesarian operation, consists in opening the 
abdominal and uterine walls with a knife, in extracting the foetus 
and its appendages through this artificial passage, and subsequent 
closing of the abdomiual wall and the uterine wound by sutures. 
Under the impulse given to classic hysterotomy by Saenger's modi- 
fications Caesarian section, as practiced at the present time, gives 
results much superior to Porro's operation. In the ulterior course 
of this description, then, I shall have exclusively in view classic 
hysterotomy, only incidentally speaking of Porro's operation. 

Preliminary precautions. 

Moment to choose for the operation. — It seems preferable not to 
wait for the beginning of labor, but to choose the last days of preg- 
nancy before the appearance of the pains. In this way all the 
preparations may be made with great care and all the conditions 
favorable to success are more easily united. It has been objected 
that this period exposes to uterine inertia, but this objection has 
not been proven and is not probable, for the uterus is equally 
retractile at all the periods of the puerperal state. 

Necessary instruments. — Ordinary and probe-pointed knives, dis- 
secting forceps, a dozen haemostatic forceps, scissors, Eeverdin's 
needle, ordinary needles and a needle-holder, silk thread of two 
sizes, hot and cold antiseptic solutions, soap, brush and razor for 



Hysterotomy. — Ccssarean Section. 433 

the antisepsis of the abdominal wall, ether, a dozen antiscptii 
towels, iodoform gauze in strips and in squares, iodoform in 
powder, a dozen sponges, six large and six small, antiseptic cotton, 
bandage, obstetrical forceps, solution of ergotine and a hypodermic 
syringe. 

Anaesthesia should be made with chloroform. 

Assistants.— One for anaesthesia, one for the abdomen, one for the 
instruments and one to receive the child. Two others for emer- 
gencies. 

Various precautions.— YulYO-Yaginol antisepsis for four or five days 
before the operation. One or two baths during the two or three 
days previous to the intervention. Laxative the evening before the 
operation. 

Before operating, while anaesthesia is being made, catheterism of 
the bladder. Shave all the subumbilical region, terminating this 
by washing with ether. Wrap up the lower limbs and the thorax 
to prevent chilling. 

Operation. — The operation is performed in three stages : 
a. Peiietration to the ovum. 

1. Incision of the abdominal wall. 

2. Incision of the uterine wall. 
h. Extraction of the ovum. 

3. Extraction of the child. 

4. Extraction of the appendages. 
c. Sutures. 

5. Sutures of the uterus. 

6. Sutures of the abdominal wall. 

1. Incision of the abdominal wall. — Incision of fifteen centimetres 
on the median line, starting four fingers' breadth above the symphy- 
sis pubis and passing around the umbilicus, preferably to the left 
to avoid the suspensory ligament of the liver (Fig. 531). 

2. Incision of the uterine ivall. — The uterus being laid bare, it is 
brought up and maintained in the median line ; the assistant is 
directed to apply the abdominal wall firmly on the organ to avoid 
the escape of the liquor amnii into the peritonaeal cavity. On the 
median line, parallel to the abdominal incision, the uterus is 
punctured with the knife at a point where palpation cannot detect 
any foetal part. Into the button-hole thus created, the finger is 
introduced to serve as a guide for the incision of the uterine wall. 

3. Extraction of the child (Fig. 532). — At the opening thus created, 
through which the liquor amnii escapes in abundance, or a foetal 
part, head, breech, or intermediate part of the trunk quickly 
presents. Sometimes the retraction and the contraction of the 



434 



Hysterotomy. — C cesarean Section, 



uterus are sufficiently energetic to push the foetus into the artificial 
opening. It is then sufficient to aid this exit. If this does not occur 
extraction is performed, either by the aid of the forceps (if the head 
presents) or by the use of the hand (if the trunk presents). The 
cord is tied and cut and the child is immediately given to the person 
who is to receive it. 




Fig. 531. — Caesarian operation. Incision of the abdominal wall. 




Fig. 532. — Caesarian operation. Extraction of the child. 

4. Extraction of the appendages (Fig. 533). — The right hand is 
passed at once into the uterus to seize the appendages, as in an 
artificial delivery of the appendages. The placenta and the mem- 
branes are brought out through the utero-abdominal opening. 



Hysterotomy.— Ccssarccm Section. 435 

5. Sutures of the uterus (Sanger).— After haying carefuUy cleansed 
ail the internal surface of the uterus and assuring the permeability 
of the cervical canal, the uterine wall is closed by the use of deep 
and of superficial sutures (of silk). 



\ ~ 




Fig. 533 —Caesarian operation. Extraction of the appendages. 



The deep sutures should be placed at one centimetre and one- 
half from each other, not including the uterine mucosa (Fig. 534), 
but passing at some millimetres above it to avoid any communication' 
by the intermediary of the threads, hetween the uterine and the 
peritonaeal cavities. 



Superficial suture 
Deep suture, 



Peritonaeum, 1 



Uterine 
Muscle. 



Mucosa. 




Fig. 534. — Sutures of the uterine 
wall, view of a section. 



^^^' 535- — The same, seen from 
above after completion. 



The superficial sutures should be placed one-half centimetre 
apart, two between each deep suture (Fig. 535). It is important to 
assure coaptation of the peritonaeal lips. The sutures are placed so 
that the free edges of the peritonaeum are fixed and maintained in 
the wound by the tension of the stitches. 

6. Sutures of the abdominal ivall. — Before proceeding to these 
sutures, it is necessary to make the toilet of the peritonaeum by the 
use of aseptic sponges to collect all the liquids that have passed into 



436 



Hysterotomy. — C cesarean Section, 



the serous cavity. The deep sutures, placed at one centimetre and 
a half from each other, should comprise the free edge of the peri- 
tonaeum (Fig. 536). The superficial stitches are placed at one-half 
centimetre from each other (two between each deep suture) and do 
not require any special precaution (Fig. 537). Drainage is useless. 
A simple dressing of iodoform gauze, maintained by a bandage, is 
adapted. The consecutive treatment is analogous to that after a 
laparotomy. 



Superficial 



Deep 


suture 
Skin 

ninal 
wall 

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Perito 


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Fig. 536. — Sutures of the abdominal 
wall, view of a section. 



Fig. 537. — The same seen from 
above after completion. 



Porro's operation consists in removing the body of the uterus. 
To this effect the body of the uterus being brought outside the 
abdomen it is transfixed at the union of the body and the cervix by 
two metallic pins. Above these pins is slipped a loop of wire to 
constrict the pedicle. For greater security it is better to place 
below the pins a second wire-loop. The uterus is excised at tw^o 
centimetres above the constricting wire and the stump, thus consti- 
tuted is fixed in the abdominal w^ound, which is closed as completely 
as possible by the use of ordinary sutures. The wdreloop, the pins 
and the ligatures are removed at the end of a time which will vary 
with the rapidity of the pedicle and of the w^ound. 

Porro's operation should be reserved for exceptionally grave cases 
and those where putrefaction of the ovum in the uterine cavity or 
a septic process causes fear that the uterus may be affected by 
septicaemia. 






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